TABLE OF CONTENTS

A Novel Oral GLP-1 Receptor Agonist: Rybelsus

(semaglutide) ...................................................... 2
Executive Control-related Prefrontal Cortex
Activity as a Biomarker of Resilience in Mental
Illness .................................................................. 3
Stress and Burnout in Pharmacy School and How
to Build Resiliency................................................ 4
Are Insurance Companies Doing Enough to Help
with the Opioid Crisis? ......................................... 5
Clinical Skills Competition .................................... 6
Keeping Things in Check with Tech-Check-Tech
Programs ............................................................. 7
The Institute Experience and Drug Overdose
Treatment in the ED............................................. 8
A Summer at Camp Boggy Creek .......................... 9
Smart Inhalers ................................................... 10
Infectious Disease Guideline Updates in 2019 .... 11
Research Experience at School ........................... 12
Xenleta (lefamulin): A Newly Approved Drug for
CABP ................................................................. 13
A Nontraditional HIPPE Rotation ....................... 14
Diabetes Management Updates 2019 ................ 15
New Areas of Collaborative Practice .................. 16
A Novel Oral GLP-1 Receptor Agonist:
Rybelsus (semaglutide)
Krystal Velez and Kimberly Ly
In September 2019, the FDA announced the approval of
Rybelsus® (semaglutide) tablets, the first oral glucagon-
like peptide 1 (GLP-1) receptor agonist for the treatment
of Type 2 Diabetes Mellitus (T2DM) in adults. This is a
novel dosage form within this drug class, as all of the
previously approved GLP-1 agonists are injectable forms.
The availability of an oral GLP-1 receptor agonist will
serve to increase adherence and the number of potential
candidates for therapy with these agents as many
patients want to avoid injectable medications while
others are not physically able to self-inject. Rybelsus® is
meant to be used as an adjunct to diet and exercise and
is not recommended as first-line therapy for patients
inadequately controlled on diet and exercise.1 Per the
ADA guidelines for the pharmacological treatment of
T2DM, GLP-1 receptor agonists are recommended for
patients with established atherosclerotic cardiovascular
disease who are uncontrolled with metformin and
lifestyle modifications. They are also a treatment option
for patients without established atherosclerotic
cardiovascular disease with a compelling need to
decrease hypoglycemia and minimize weight gain or
promote weight loss.2
Glucagon-like peptide 1 (GLP-1) receptor agonists mimic
incretin hormones and exert their glucose lowering
effect by stimulating insulin secretion from the
pancreatic islets in a glucose-dependent manner, with a
low risk for hypoglycemia.3,4 They have also been shown
to decrease inappropriate postprandial glucagon release
as well as slow gastric emptying, the latter of which may
contribute to their potential to cause weight loss in some
patients. GLP-1 receptor agonists have demonstrated a
cardiovascular benefit over other antidiabetic therapies,
hence their recommendation for patients with
established ASCVD by the ADA. In a study published in
the New England Journal of Medicine, the cardiovascular
risk profile of Rybelsus® was shown to be noninferior to
that of placebo. Death from cardiovascular causes
occurred in 15 of 1591 patients (0.9%) in the Rybelsus®
group compared to 30 of 1592 patients (1.9%) in the
placebo group (HR 0.49; 95% CI 0.27 - 0.92).2 Reductions
in A1C (mean difference 0.7%), weight (mean difference
3.4 kg), and systolic blood pressure were greater in the
Rybelsus® group than in the placebo group.4
Rybelsus® should be taken at least 30 minutes before the
first food, beverage, or other oral medications of the day
with no more than 4 ounces of plain water only. Waiting
less than 30 minutes or taking Rybelsus® with anything
other than what was previously stated will lessen the
effect of Rybelsus® by decreasing its absorption. Waiting
more than 30 minutes to eat may lead to unwanted
adverse effects due to increased absorption of
Rybelsus®.3 Dose reductions should also be considered in
patients on insulin therapy to prevent hypoglycemia.
Patients should be thoroughly educated on how to
properly take this medication to ensure maximum
efficacy and must be provided with a Medication Guide
with every fill.
It should be noted that Rybelsus® is not indicated for the
treatment of type 1 diabetes mellitus or diabetic
ketoacidosis.5 Rybelsus® has not been studied in patients
with a history of pancreatitis.5 Common adverse
reactions reported in ≥5% of patients treated with
semaglutide, include nausea, abdominal pain, diarrhea,
decreased appetite, vomiting and constipation.5 Caution
should be taken when Rybelsus® is coadministered with
levothyroxine as semaglutide’s delayed gastric emptying
effects and subsequent impact on absorption caused a
33% increase in exposure of levothyroxine (90% CI: 125-
142).5 Use in pregnant or lactating mothers is not
recommended as there is a potential for fetal harm.5
Patients with acute kidney injury or diabetic retinopathy
should be closely monitored on Rybelsus® in an effort to
prevent any further complications.5
Even with these considerations, Rybelsus® shows great
promise in helping patients with T2DM achieve glycemic
control. Rybelsus® is specifically a valuable alternative
for patients who are not able to use injectable
medications (like insulin) but require more aggressive
therapy to get their A1C and/or T2DM under control.

References
1. UpToDate [Internet]. Uptodate.com. 2019 [cited
2019 Oct 6]. Available from:
https://www.uptodate.com/contents/glucagon-like-
peptide-1-receptor-agonists-for-the-treatment-of-
type-2-diabetes-mellitus
2. Husain M, Birkenfeld A, Donsmark M, et al. Oral
Semaglutide and Cardiovascular Outcomes in
Patients with Type 2 Diabetes. New England Journal
of Medicine. 2019;381(9):841-851.
3. Davies M, Pieber T, Hartoft-Nielsen M, et al. Effect
of Oral Semaglutide Compared With Placebo and
Subcutaneous Semaglutide on Glycemic Control in
Patients With Type 2 Diabetes. JAMA.
2017;318(15):1460.
4. Pharmacologic Approaches to Glycemic Treatment:
Standards of Medical Care in Diabetes—2019.
Diabetes Care. 2018;42(Supplement 1):S90-S102.
5. Rybelsus® (semaglutide) tablets [package insert].
Plainsboro, NJ: Novo Nordisk; 2019.
Executive Control-related Prefrontal
Cortex Activity as a Biomarker of
Resilience in Mental Illness
Caroline Leeflang and Gabriella Perez
There have been multiple studies in recent years looking
for biomarkers which signify the possible development
of mental illness. Biomarkers have been important
factors in diagnosing mental illness, specifically mood
disorders, as they may predict the development of
conditions such as posttraumatic stress disorder (PTSD),
alcohol abuse disorder, and depression. However, this
article focuses on biomarkers of ‘resilience’ to stress
which would decrease the risk of developing anxiety,
rather than a biomarker which tests for anxiety itself.
The study population consisted of 120 university-age
students who gave informed consent and successfully
participated in the Duke Neurogenetics Study. No
participants were taking psychotropic medications
within 10 days of participation in the study, and over 19%
of the participants had a current or past history of
depression or alcohol abuse. Participants were excluded
if they had a history of cancer, stroke, chronic
liver/kidney disease, diabetes, psychotic disorders or
were receiving glucocorticoids and/or hyperlipidemic
medications. Multiple self-report questionnaires were
used to evaluate symptoms, life events, and childhood
trauma. All participants were also administered a clinical
and neuropsychological interview.
The study incorporated the use of 3 instrumental
paradigms to assess response across 3 regions of the
brain: the ventral striatum (VS), the amygdala, and the
dorsal prefrontal cortex (dlPFC). The first functional MRI
(fMRI) paradigm in the study was used to capture a
strong, repeatable amygdala response; it used face and
shape matching and variable interstimulus intervals to
maximize amygdala reactivity. The second fMRI
paradigm involved the VS and emotional response to risk
and reward. Participants were led to believe their
decisions resulted in monetary gain when in reality, each
participant received equal monetary compensation
regardless of performance. The final paradigm measured
dlPFC activity using an event-related working memory
program. Participants completed a series of three tasks
which tested various working memory conditions, and
linear contrast was used to estimate effects on each
participant. This contrast correlates with common coping
strategies used in daily life as well as depressed mood
and anxiety symptoms associated with stressful life
events.
The 3 fMRI strategies used showed significant activity in
the regions of interest and interaction between the three
regions that predicted a change in anxiety. An interaction
was discovered between VS and amygdala activity which
caused increases in anxiety at low and average levels of
dlPFC activity, but not high levels. When accounting for
patient population differences such as sex, age, IQ, and
recent stress, the study concluded the total model of 3-
systems accounted for 42% of the change in anxiety.
These conclusions suggest high dlPFC activity could
signify higher levels of resilience and decreased risk for
future anxiety associated with the amygdala and VS
activity. The findings could be used to identify high-risk
individuals who could benefit from psychotherapy and
see decreased likelihood of subsequent anxiety.
References
1. Scult, M. A., Knodt, A. R., Radtke, S. R., Brigidi, B. D., &
Hariri, A. R. (2017). Prefrontal Executive Control Rescues
Risk for Anxiety Associated with High Threat and Low
Reward Brain Function. Cerebral Cortex, 29(1), 70–76. doi:
10.1093/cercor/bhx304
Stress and Burnout in Pharmacy
School and How to Build Resiliency
Jessica Conn and Tracy Tolf
What is the difference between stress and burnout?
According to the National Academy of Medicine (NAM),
burnout is defined as a syndrome characterized by a
“high degree of emotional exhaustion,
depersonalization, and a low sense of personal
accomplishment at work.”3 Burnout is commonly caused
by experiencing high levels of stress over a long period of
time. Some of the key differences between stress and
burnout are listed in the infographic below.1
How do you combat stress and burnout? Building
resilience (adapting well in the face of adversity, trauma,
tragedy, threats, or significant sources of stress) is one
way.2 Keeping your well-being in check is another. Well-
being is defined as the presence of positive emotions and
moods, the absence of negative emotions, satisfaction
with life, fulfillment, and positive function.2
It has been published since the 1980s that pharmacy
school students need courses on stress management and
life planning.2 The University of Florida College of
Pharmacy has heard students’ concerns about mental
health and well-being. Our campus now has a counselor
from the UF Counseling and Wellness Center who visits
periodically for appointments. UF also started a pilot
elective this fall semester which meets weekly to help
students learn skills and various approaches to alleviate
stress and improve self-awareness and self-care. Keep an
eye out for the spring registration of this “Integrated
Mind-Body Skills” 10-week course. The space in this
course is limited but is offered on all three campuses.
Professional pharmacy organizations can play a role in
this as well and it has been recommended in an ASHP
article that organizations take part in resilience building.2
Our organizations at the Orlando campus do a great job
of holding extracurricular events which allow students to
participate in non-academic related activities such as the
annual flag-football tournament held by our very own
Florida Society of Health-System Pharmacists (FSHP)
student chapter. Organizations could collaborate on a
mental health initiative with various events that promote
well-being and resilience among students. This initiative
could offer events such as physical activities for stress
relief, promoting healthy eating through quick and
healthy options being provided or showing students how
to make a healthy quick meal at home. Organizations
should also promote serving the community because of
the personal reward one gains from spending time
helping others.
As an individual, there are three strategies which have
been studied that you can do to achieve higher levels of
well-being.2 They include savoring the moment,
behavioral display and capitalizing. Savoring the moment
forces the individual to focus in on the present, and to
live in the now. This technique also drives the individual
to focus on the positives throughout the day rather than
dwell on the negatives. The behavioral display strategy is
to express positive emotions with nonverbal behaviors.
Capitalizing includes the communication and celebration
of positive events with other people.
The book Flourish by Martin Seligman, has detailed
tactics to improve well-being and resilience.2 One
exercise is called the “three good things” exercise. This
exercise has the individual physically write down three
positive things each day. By focusing on three positive
things that happened during the day you are savoring
those events and
feelings of joy
and
accomplishment.
While it has been
shown that
focused group
discussions are
most effective, there are several other methods you can
incorporate into your routine to help with stress relief.
Find a healthy support system and learn what works
best for you to relieve stress whether it’s hitting the
gym or spending quality time with friends. You can also
try a free trial of a mindfulness application (or search
YouTube) such as Headspace or Calm. The important
thing is that you discover what works for you and make
time to manage stress and avoid burnout.
RESOURCES:
● Dr. Philip Daniels, UF College of Pharmacy
Mental Health Counselor. For more information
or to set up an appointment contact him at
pdaniels@ufl.edu.
● Crisis Text Line (any type of crisis, 24/7 support):
Text CONNECT to 741741.
● National Suicide Prevention Lifeline: 1-800-273-
8255.
References
1. Louie, Jessica. “6. Stress vs. Burnout, How are they
different?” The Burnout Doctor Podcast, Apple
Podcasts, July 8th, 2019,
https://podcasts.apple.com/us/podcast/the-
burnout-doctor-
podcast/id1470133258?i=1000443906901.
2. Kai Kang, Claudia F Ortiz Lopez, Brittany S Fear,
Robert P Granko, Tactics to improve resilience and
well-being among pharmacy students, American
Journal of Health-System Pharmacy, Volume 76,
Issue 18, 15 September 2019, Pages 1374–1376,
https://doi.org/10.1093/ajhp/zxz143
3. Kate Traynor, Pharmacists examine risks, remedies
for burnout, American Journal of Health-System
Pharmacy, Volume 76, Issue 9, 1 May 2019, Pages
571–573, https://doi.org/10.1093/ajhp/zxz042
Are Insurance Companies Doing
Enough to Help with the Opioid Crisis?
Elaine Altamura
In Florida, there have been two bills introduced this year
outlining the responsibility of insurance companies to
meet the needs of a society with patients seeking opioid
abuse treatment. Both bills have died.[1]
SB360/HB307[2] are the same bill that talk about different
reports which are required to be submitted annually
from insurance companies and the Office of Insurance
Regulation about the methodology used for compliance
with the federal parity law. The federal parity law helps
to ensure mental health issues are treated fairly with
other medical conditions. This bill would have also
required insurance companies to offer mental health and
substance use disease benefits as defined by the
American Psychiatric Association Diagnostic and
Statistical Manual #5. This bill died in the Senate at the
banking and insurance subcommittee and died in the
House at the health market reform subcommittee.
SB700/HB695[3] are the same bill that talk about changes
to insurance benefits regarding mental health. In
summary, “…change previously optional mental health
benefits to required benefits that must be offered by
group insurance policies or contracts at no additional
premium and with no greater cost-sharing limitations
than imposed on other medical benefits." This includes
"drug abuse rehabilitation programs shall also be
qualified providers under this section." This was another
attempt at having more access for patients by giving the
option of more affordable treatment options. This bill
died in the Senate at the banking and insurance
subcommittee and in the House it was withdrawn.
In Colorado, a bill has been signed into law by the
governor in May 2018 addressing drug prices in regards
to substance use disorder.[4] This bill requires insurance
companies to have the responsibility of providing
insurance members with the opportunity to seek
substance abuse treatment. "The act requires all
individual and group health benefit plans to provide
coverage without prior authorization for a 5-day supply
of at least one of the FDA-approved drugs for the
treatment of opioid dependence for a first request within
a 12-month period." People can have access to a
treatment option faster without needing to run around
in "red-tape" waiting for their treatment to be approved.
In conclusion, Florida is still working on passing
legislation that will meet the standard of Colorado
legislation in making substance abuse disease treatment
options available and affordable to people seeking
treatment. It is important to look at another state’s
legislation to see how Florida can help its own citizens
through this crisis. Florida has been helping slow down
the opioid crisis in other ways.[5] The state’s target has
been to focus on education of prescribers and
standardizing doses which can be dispensed to patients.
The state has also required tracking opioid medications
through the Florida Enhanced State Opioid Overdose
Surveillance Program (FL-ESOOS).[6] This surveillance
program documents when patients are getting
controlled substances from the pharmacy to monitor
trends and risks in substance abuse.

While there has been a decreasing trend in the number
of opioids prescribed, Florida is still above the US average
for overdose deaths in 2017 with 25.1 per 100,000
persons overdosing in Florida.[7] Deaths are still on the
rise and the need for treatment is demanding Florida’s
legislation to fight for their citizens.
References
1. Florida Legislation. (2019, June 24). Parity Track.
Retrieved from
https://www.paritytrack.org/report/florida/florida-
legislation/
2. The Florida Senate. Senate Bill 360 (2019) - The Florida
Senate. Retrieved from
https://www.flsenate.gov/Session/Bill/2019/00360/?Tab
=RelatedBills
3. The Florida House. HB 695 (2019) - Insurance Coverage
for Mental and Nervous Disorders | Florida House of
Representatives. Retrieved from
https://www.myfloridahouse.gov/Sections/Bills/billsdeta
il.aspx?BillId=64213&
4. Colorado General Assembly. (2018, May 3) Substance
Use Disorder Payment And Coverage. Retrieved from
https://leg.colorado.gov/bills/hb18-1007
5. Centers for Disease Control and Prevention. (last
reviewed 2019, July 29) State Successes. Retrieved from
https://www.cdc.gov/drugoverdose/policy/successes.ht
ml
6. Florida Health. (2019, Sep. 12) Florida Enhanced State
Opioid Overdose Surveillance Program (FL-ESOOS).
Retrieved from http://www.floridahealth.gov/statistics-
and-data/fl-esoos/
7. National Institute of Drug Abuse. (last updated 2019,
May) Florida Opioid Summary. Retrieved from
https://www.drugabuse.gov/drugs-
abuse/opioids/opioid-summaries-by-state/florida-opioid-
summary#targetText=The%20age%2Dadjusted%20rate%
20of,2017%20(25.1%20per%20100%2C000).
Clinical Skills Competition
Amara Yunus and Matthew Doenges
This semester, we had the opportunity to compete in the
local Clinical Skills Competition at the UF Orlando
Campus. For those unfamiliar with the competition, it is
held by ASHP to provide pharmacy students with an
opportunity to enhance their clinical knowledge and
skills as well as to showcase what they have learned. The
event consists of a local competition held at the campus
and multi-campus levels as well as a national
competition at the ASHP midyear meeting in December.
After speaking with various students who have
competed in the past, the two of us decided to put our
skills to the test. Despite having minimal clinical
knowledge or understanding on how to work-up and
present a patient, we wanted to compete not only to test
the knowledge we already have but also to learn and
grow from this experience.
The format of the competition is similar to being on APPE
Clinical Rotations. When we first began, we were given a
patient case to assess and two hours to create a written
pharmacist care plan, which included a prioritized
problem list. After these two hours, we presented our
highest priority problem and therapy plan for this
problem to a panel of judges, who are practicing
pharmacists, followed by questions about our plan,
similar to presenting a patient to a preceptor.
The Clinical Skills Competition showed us how important
it is to work in healthcare teams. When working with
others, it is essential to utilize the strengths of everyone
on that team. By working together, the two of us were
able to look at the patient from different perspectives.
One of us would sometimes catch something the other
missed. In this scenario, it is also important to make sure
you are paying attention to what your partner is doing
and vice versa so that the entire team is aware of the
patient care plan.
Through the competition, we also learned how to work
up a patient. This early in our careers, the most exposure
we have had was in skills lab, coincidentally on the same
day as the competition. We realized that although it is
essential to have a strong clinical background, having the
ability to properly and efficiently utilize your resources is
essential. Not only do you need to know what to look for,
you need to know how to look for it.
Participating in the Clinical Skills Competition this early in
our pharmacy career was an extremely rewarding
experience. The competition allowed us to build upon
the foundation we have laid up to this point in pharmacy
school. Despite the two of us both having jobs in a clinical
setting, this was certainly eye-opening as far as how to
really work-up a patient. Having only just learned about
the appropriate technique in skills lab in the past couple
weeks, it reinforced how to do so appropriately in a
different setting and how it can change based on the
specific needs of the patient. A lesson to other students:
do not let your level of clinical knowledge deter you from
taking a chance in this competition. We did not and could
not be more grateful for the opportunity.
Keeping Things in Check with Tech-
Check-Tech Programs
Rachel Helgemoe
The pharmacist always performs the final verification,
right? Although this has been the norm for decades, this
may not be the case going forward. Doing the final
verification of work another technician has completed is
a relatively new responsibility pharmacy technicians
have been taking on. Below are some questions and
answers about what a "technician-checking-technician"
(TCT) process is.
1. What is a TCT process?
A TCT process is where a specially trained pharmacy
technician is allowed to do the final verification check of
another technician's work. The scope of what a checking
technician can do is very site-specific and depends on the
institution and state regulations.
2. What are the qualifications necessary for TCT
technicians?
Each pharmacy and healthcare institution differ on the
requirements, but certain places have required some
combination of the following: being nationally certified
with the PTCB, having at least 2000 hours of practice
experience, having graduated from an accredited
technician training program, and/or having at least three
years of work experience (Frost, 2016).
3. What are examples of what a TCT-trained technician
can check?
Each pharmacy and healthcare institution differ on what
TCT processes are allowed, but some TCT programs have
included doing the final verification on refills, completing
medication order entry, and completing the second
check for medication cart fills for automated dispensing
cabinets.
4. Is the checking accuracy of a technician comparable
to that of a pharmacist?
In small studies and analyses, the accuracy of technicians
performing final checks was found to be comparable to
that of pharmacists (Adams, 2011). However, there may
have been some confounding factors in that the
technicians were aware they were being monitored for
accuracy over the study period and thus paid more
attention to detail than perhaps they would have
normally.
5. If the pharmacist has decreased responsibility in
checking medications, what does that mean for the
profession of pharmacy?
Since the TCT process frees up time for the pharmacist to
work on clinical services and patient-centered activities
(Miller, 2018), this can be seen as a benefit for
pharmacists, in that it allows pharmacists to practice at
the top of their license. However, in an article about the
TCT topic, the Pharmacy Times website opined that “with
more pharmacy school openings, falling reimbursement
rates, changing health care coverage models, and a trend
toward automation across many industries, [some]
pharmacists worry TCT programs are a step in the wrong
direction for the profession.”
I discussed this topic with various technicians and
pharmacists, and there were mixed reactions to this
process from both parties.
Pharmacist view: Some pharmacists have said they
would feel uncomfortable and feel a certain loss of
control with medications leaving the pharmacy which
have not been checked by a pharmacist, but with time,
perhaps they would get used to this new way of doing
things. They recognized certain processes have been
changing in recent years at different institutions, such as
pharmacists working remotely to check sterile products
from the IV room, using photographs of the components;
so again, new processes take time to get used to. The
pharmacists mentioned having a TCT process would free
up more time for them to do clinical activities which
would be beneficial.
Technician view: Technicians noted a TCT process may be
beneficial in getting items checked more quickly, since
pharmacists can oftentimes get caught up with order
verification, physician and nurse phone calls, and other
clinical activities. However, the technicians said they
would have varying levels of comfort with this process
depending on which technician would be doing the
checking, as certain technicians are more attentive to
detail and/or have more experience and know what
common mistakes to look out for (e.g. sound-alike look-
alike drugs and small differences between different
product types and formulations). Also, the technicians
mentioned they would feel more comfortable in having
the TCT process in place with things which involve
barcode scanning. For example, they would be alright
with a TCT technician checking an automated dispensing
cabinet cart fill which will later involve barcode scanning
because the barcode acts as a final check in a certain
way.
In conclusion, TCT processes have been in place for a
number of years but have not gained traction yet due to
concerns about taking away the pharmacist's
responsibility to do the final verification check. Small
studies in a limited number of places have showed
promising results for implementing TCT, but more
research is needed in this area to determine if
technicians can consistently and accurately complete
final verifications checks.
References
1. Adams, A. J., Martin, S. J., & Stolpe, S. F. (2011).
“Tech-check-tech”: A review of the evidence on its
safety and benefits. American Journal of Health-
System Pharmacy, 68(19), 1824–1833. doi:
10.2146/ajhp110022
2. Frost, T. P., & Adams, A. J. (2016). Tech-Check-Tech
in Community Pharmacy Practice Settings. Journal of
Pharmacy Technology, 33(2), 47–52. doi:
10.1177/8755122516683519
3. Miller, R. F., Cesarz, J., & Rough, S. (2018).
Evaluation of community pharmacy tech-check-tech
as a strategy for practice advancement. Journal of
the American Pharmacists Association, 58(6), 652–
658. doi: 10.1016/j.japh.2018.06.018
4. Tech-Check-Tech Programs: What Pharmacists Need
to Know. Retrieved from
https://www.pharmacytimes.com/news/tech-check-
tech-programs-what-pharmacists-need-to-know.
The Institute Experience and Drug
Overdose Treatment in the ED
Anel Couzo
In late May 2019, I traveled to my first graduate school
summer conference. I went to beautiful and
mountainous Salt Lake City, Utah, known as The Beehive
State. Initially, what captivated my attention about this
conference was the natural beauty and recreation of the
Rockies, but these were just additive benefits. I was
about to expose myself to a topic I honestly knew very
little about. This conference is called APhA Institute of
Substance Abuse Disorders. The Institute
has been around for many years and has served as a
welcoming retreat to pharmacy students and
practitioners to learn and understand the disease of
addiction. It is an experience which can be very
emotionally touching, even if the topic is foreign to you.
In order to attend, students needed to be selected
through submission of an application, which
includes a written essay. It is a selective process because
the conference is small. The agenda includes talks by
outstanding pharmacists, researchers, physicians, and
psychologists. The topic of addiction goes hand in hand
with treatment and recovery. Discussion of addiction
also needs to address the feelings of guilt and
hopelessness which oftentimes accompanies people
who have abused substances chronically and cannot
walk away from such a need. Stigma has been for a long
time the single biggest obstacle in deciding to seek help.
Emergency Medical Services (EMS) and the Emergency
Department (ED) are oftentimes first-line rescue teams
in drug overdose situations. The best single rescue
medication is naloxone, with significant proof of
effectiveness (Kerensky 2017). Patients with a history of
substance abuse are at a higher risk of abusing
prescriptions/illicit drugs. In the ED, symptoms and signs
that can help with diagnosis are increased heart rate,
increased blood pressure, increased temperature, pupil
dilation, and presence of diaphoresis. Medications like
anticholinergics, cholinergics, opioids,
sympathomimetics, and sedative-hypnotics can all
influence the responses above. Since 2013, there has
been a continuous increase in opioid-overdose deaths
related to synthetic opioids like tramadol and fentanyl,
either prescribed or purchased illicitly (CDC, 2019).
Fentanyl has double the potency of heroin and 100%
more potency than morphine. Other substances of abuse
are U-47700 Pink, Kratom (has opioid-like properties),
Kmax (similar to ketamine and can be purchased on the
internet). Agitated patients with symptoms due to
psychoactive compounds like bath salts are typically
treated with lorazepam in the ED. Methamphetamine
intoxication manifests with a wide range of signs and
symptoms including violent episodes and advanced
cardiac complications like cardiac ischemia. It is treated
with benzodiazepines. Cocaine, a CNS stimulant often
cut with another agent, is also treated in the ED with
lorazepam or midazolam for cases of overdose.
Besides immediate treatment necessary in emergency
situations, patients suffering from drug dependencies
need to have a combination of pharmacological
treatment and addiction counseling in order to succeed.
This disease affects the individual and their families, their
employment status, and their friendships. The Institute
shared the stories and the faces of this disease. Many
have fought and many still fight every day against drug
addiction, but not everyone wins. Pharmacists are
privileged to understand medications. Now, it is time to
understand the disease progression and the
psychological implications of it to improve assistance in
emergency situations and also in long-term treatment.
References
1. Center for Disease Control and Prevention, 2019.
2. Kerensky, T., Walley, A.Y. (2017). Opioid overdose
prevention and naloxone rescue kits: what we know
and what we don’t know. Addiction science &
clinical practice, 12(1), 4. doi:10.1186/s13722-016-
0068-3
A Summer at Camp Boggy Creek
Tracy Tolf and Devi Surajbali
Camp Boggy Creek is a summer camp in Eustis, Florida
for children with critical illnesses. Over the past several
years, the UF Orlando campus has been afforded the
opportunity to volunteer with the camp through
assisting the nursing staff with the check-in process. This
camp provides the unique opportunity for children with
similar illnesses to build relations with one another - and
to just have fun! Camp Boggy Creek’s mission is to foster
a spirit of joy by creating a free, safe and medically-sound
camp environment which enriches the lives of children
with serious illnesses and their families.
On camp intake day, our pharmacy students arrive at the
camp around 11:30 am. Each week, the health condition
theme changes ranging from cardiac diseases to
epilepsy. Upon arrival, we are given a brief tour of the
main camp building, known as “The Patch”, where we
will perform our duties later that day. We are then
provided lunch with other camp counselors before
preparing for check-in. As the campers suffer from
serious illnesses, most of them have strict medication
regimens they must adhere to. This is where our
pharmacy background comes into play, and we take their
medications and begin to organize them by the time of
day they must be taken. We, in conjunction with the
nursing staff, were ultimately tasked with the
responsibility of ensuring that each child would receive
their medications at the right time throughout the day in
the midst of all of the exciting activities planned for them
that week.
It was amazing how proactive each child was in knowing
and understanding their medication regimens. These
kids knew everything - even brand name to generic
conversions of their medications! A few of the campers
Tracy checked in needed to give themselves a treatment
one of the days that they were at camp. It was
convenient because the nurse she was with knew exactly
what questions to ask them about how they want to
administer the treatment to themselves and even who to
talk to when it gets to that time. The children were
confident they could administer the treatments by
themselves, they just needed the space to complete their
treatments in. It was super impressive. For Devi, it was
heartwarming to see how thankful the parents were for
our help. Caring for a child with a multitude of illnesses
can take its toll on a family. For some, this was the only
opportunity they had to take care of other personal
matters without having to worry about whether or not
their child would be okay. What was even more special
to her was seeing children return to the camp and
reunite with friends they made the year before. The work
being done at Camp Boggy Creek is special and Devi was
extremely humbled to be a part of it.
This camp not only creates peace of mind for the parents
of these children to know that nurses and doctors are on
site and available 24 hours a day for their children, but
the children themselves also feel at ease. They know all
the other children at the camp have a similar disease to
them so it really helped build up the camaraderie
amongst them. When Tracy would prepare to help check
in the next camper, she saw the families talking with one
another and all the children making friends before they
even started camp.
Overall, this volunteer experience at Camp Boggy Creek
was an amazing one to say the least. In pharmacy school,
we think of most of our
patients being self-sufficient
adults and so this opportunity
helped broaden our
understanding of patient
centered care. It was extremely
inspiring and rewarding to
have our FSHP Chapter volunteer at this camp. We highly
recommend anyone who is interested in it to sign up!
Smart Inhalers
Kareem Taha and Sean Harris
Inhaled corticosteroids and bronchodilators are the
current standard therapies for treatment of asthma.
Inhaled corticosteroids prevent attacks and control
inflammation while bronchodilators relieve symptoms. If
used properly, inhaled therapy is proven to be safe and
effective, however, up to 94% of patients do not use their
inhalers correctly.1 The current approach to solving
adherence and inhaler technique errors through
counseling patients has demonstrated to be difficult. The
use of smart inhalers can help curb these issues.
Electronic inhalers are not entirely new concepts. The
pMDI electronic inhaler, SmartMist®, was developed over
20 years ago. It could measure the coordination between
dose actuation and inhalation, as well as measure the
inhalation flow and volume.2 However, it was removed
due to cost and patient reluctance to this type of
monitoring. The newer smart inhalers contain an e-
module with a sensor that transmits information through
Bluetooth to a smartphone, which records the events
and uploads this information to a remote server. It is able
to record the date, time, place, and whether the dose
was correctly administered. For example, smart inhalers
have the potential to give instant feedback about
inhalation technique, such as inhaling faster or slower.
They also can remind patients to take their medication.
Smart inhalers can provide accurate monitoring for
clinicians through the use of mobile apps, predictive
analytics, and feedback to help patients and clinicians
best manage the disease. Most of the smart inhalers
currently available or being developed are external add-
on modules, but there are some which are fully
integrated into the inhaler.
The ProAir Digihaler® is the first and only inhaler with
built-in sensors containing an active drug (albuterol
sulfate 117 mcg per dose) approved by the FDA.3 It is the
electronic version of the ProAir RespiClick®. The inhaler is
able to measure dosing timestamps as well as an
inhalation profile (peak inhalation flow and inhaled
volume) of each inhalation using pressure sensors. This
information can be instantly found on a smartphone
using the dedicated app. Reports on adherence as well
as inhaler technique can also be generated.
Smart inhalers can offer huge advantages to patients and
clinicians, measuring real-life adherence and inhaler
technique. However, there are some important factors
which must be considered. The majority of smart
inhalers are add-on devices that are externally attached
to the inhaler. Unlike the fully integrated e-modules,
these can only detect whether the inhaler was actuated,
and not whether the dose was inhaled, nor whether the
inhaler technique is appropriate. The cost and increased
workload associated with analyzing the reports also need
to be studied further to assess the cost effectiveness and
improved patient quality of life, respectively.
References
1. Jahedi L, Downie SR, Saini B, Chan HK, Bosnic-
Anticevich S. Inhaler Technique in Asthma: How Does
It Relate to Patients' Preferences and Attitudes
Toward Their Inhalers?. J Aerosol Med Pulm Drug
Deliv. 2017;30(1):42–52. doi:10.1089/jamp.2016.1287
2. Farr SJ, Rowe AM, Rubsamen R, Taylor G. Aerosol
deposition in the human lung following administration
from a microprocessor controlled pressurised metered
dose inhaler. Thorax, 50 (6) (1995), pp. 639-644
3. Chrystyn H, Audibert R, Keller M. Real-life inhaler
adherence and technique: Time to get smarter! Respir
Med. 2019 Sep 12;158:24-32. doi:
10.1016/j.rmed.2019.09.008. [Epub ahead of print]
Infectious Disease Guideline Updates
in 2019
Olga Ivanova and Rebecca Falter
THE INFECTIOUS DISEASES SOCIETY OF AMERICA HAS released
three updated infectious disease guidelines in 2019:
tonsillectomy in children, asymptomatic bacteriuria
and community-acquired pneumonia. These guidelines
collate treatment options which have been evaluated
in systematic reviews, randomized control trials and
observational studies and assess the strength
of evidence to create recommendations for practice.
While the guidelines are meant for a broad range of
medical practitioners, many pharmaceutical changes
exist within the updates which make an excellent
addition to a clinical pharmacist’s toolbox.
Tonsillectomy in Children (February 2019)
● Updates since the 2011 guidelines include changes
in determining who is a candidate for tonsillectomy
and in intra- and post-operative care of
tonsillectomy patients.
● Strong recommendation for administering a single
intraoperative dose of dexamethasone, based on
RCTs that show intraoperative steroids decrease
incidence of post-operative nausea and vomiting,
pain and time to resume oral intake.
● Strong recommendation for managing
postoperative pain with ibuprofen, acetaminophen
or both, based on a systematic review and RCTs
that show ibuprofen is safe to use postoperatively
and does not increase incidences of bleeding.
● Strong recommendation against administering
perioperative antibiotics to children with no other
indication for antibiotic therapy due to RCTs and
systematic reviews showing that antibiotics
provide no benefit in reducing morbidity but can
cause adverse effects.
● Strong recommendation against administering or
prescribing codeine or any product containing
codeine to children under 12 years of age, due to
observational studies and supporting
pharmacogenetic studies that demonstrate
potential life-threatening complications for
children who are ultra-metabolizers of codeine. 1
Asymptomatic Bacteriuria (March 2019)
● New 2019 guidelines address populations not
previously included in the 2005 guidelines and
touch upon the clinical presentation of
symptomatic UTI in populations with high
prevalence of asymptomatic bacteriuria (ASB).
● Screening for and treatment of ASB is
recommended against in the following population
categories: pediatric patients; healthy non-
pregnant women; older functionally impaired
persons living in the community or residing in a
long-term care facility; diabetic patients; renal
transplant patients who received renal transplant
>1 month prior; patients who received a non-renal
solid organ transplant; patients with urinary
catheters; patients undergoing elective non-
urologic surgery; patient receiving or living with
urologic devices, such as artificial urine sphincter or
penile prosthesis.
● The following patient categories should be
screened, further assessed and/or treated for ASB:
pregnant women; patients with neutropenia;
patients undergoing invasive endoscopic urologic
procedures associated with mucosal trauma;
patients with impaired voiding due to spinal cord
injury are generally recommended against
screening; however, clinical signs and symptoms of
UTI in this patient category may be different from
the classic symptoms experienced by patients with
normal sensation, consequently, making decisions
should be considered with respect to the atypical
symptomatology; for older functionally or
cognitively impaired patients with delirium or
patients who experience a fall, further assessment
and careful observation for other causes are
recommended.2
Community-Acquired Pneumonia (October 2019)
● The updated 2019 guidelines cover 16
recommendation areas including diagnostic testing
and the determination of treatment settings. Some
recommendations have not changed, however the
availability of new therapeutic trials and evidence
led to revised recommendations for the selection
of initial empiric antibiotic therapy and subsequent
disease management strategies.
● Empiric treatment (outpatient) for patients
without comorbidities or risk factors: amoxicillin;
doxycycline; a macrolide (azithromycin or
clarithromycin only in areas with pneumococcal
resistance to macrolides < 25%).
● Empiric treatment (outpatient) for patients with
comorbidities: combination therapy
amoxicillin/clavulanate or a cephalosporin
(cefpodoxime or cefuroxime); AND macrolide
(azithromycin or clarithromycin), or doxycycline;
 OR monotherapy: respiratory fluoroquinolone
(levofloxacin, moxifloxacin, or gemifloxacin).
● Empiric treatment (inpatient) in adults without
risk factors for MRSA and P. aeruginosa:
combination therapy with a beta-lactam
(ampicillin/sulbactam, cefotaxime, ceftriaxone, or
ceftaroline) and a macrolide (azithromycin or
clarithromycin); OR monotherapy with a
respiratory fluoroquinolone (either levofloxacin
or moxifloxacin). For patients with
contraindications to both macrolides and
fluoroquinolones: combination therapy with a
beta-lactam and doxycycline.
● Empiric treatment (inpatient) in adults with risk
factors for MRSA and P. aeruginosa: Empiric
treatment options for MRSA include vancomycin or
linezolid. Empiric treatment options for P.
aeruginosa include piperacillin/tazobactam,
cefepime, ceftazidime, aztreonam, meropenem, or
imipenem.3
References
1. Mitchell RB, Archer SM, et al. Clinical Practice
Guideline: Tonsillectomy in Children (Update).
Otolaryn Head and Neck Surg. 2019;160(IS):S1-S42.
2. Nicolle LE, Gupta K, et all. Clinical Practice Guidelines
for the Management of Asymptomatic Bacteriuria:
2019 Update by the Infectious Diseases Society of
America. Clin Infect Dis. 2019;68(10):e83-e110.
3. Metlay JP, Waterer GW, et al. Diagnosis and
Treatment of Adults with Community-acquired
Pneumonia. An Official Clinical Practice Guideline of
the American Thoracic Society and Infectious
Diseases Society of America. Am J of Resp and Crit
Care Med. 2019;200(7):e45-e67.
Research Experience at School
My Tran
What projects have you done on our campus?
On our campus, my first research experience was
through sPMC. Every year sPMC offers research projects
which students must apply for. I worked together with
two of my fellow classmates in order to conduct a
literature review on the current medications used in
breast cancer therapies. At the time, Dr. Bihorel was our
principal investigator. Our team successfully finished the
literature review.
My second experience was through the Summer
Intensive Research Internship on our campus as well. At
the time, I had chosen Dr. Turgeon (our Associate Dean
at the time) and his partner, Dr. Michaud. They were
absolutely my favorite research mentors I ever had. At
first, I had to conduct a literature search on the impact of
GSTA1 polymorphisms on busulfan oral clearance in
adult patients undergoing hematopoietic stem cell
transplantation.
Once I was able to satisfy questions they asked me and
they deemed my knowledge of the topic was sufficient, I
was given data to analyze. This data had been collected
at a hospital in Montreal. The data results we received
were enough for me to write an abstract. We only had
one day to submit that abstract. The next day, I learned
the abstract was accepted at a conference in Montreal!
My two P.I.s went to Montreal to present our findings.
When they came back, I was asked to write another
abstract for a different conference which was the
American Society of Clinical Pharmacology and
Therapeutics. I did not expect much but that changed
while I was at MRM. At MRM, Dr. Michaud emailed me
saying congratulations and to check my email. My
abstract received 1 of the 18 Presidential Trainee
Awards. This conference accepted applications
worldwide, so I was ecstatic my abstract was in the top
20% of the entire conference. I was even asked to be one
of the three headliner presentations as well as to present
in two other sessions. My absolute favorite part was that
everything would be compensated, and I would get to be
in DC (favorite city ever)! After the presentation, I was
asked to write a manuscript to submit to a journal which
got published.
In the end, I was able to publish 2 abstracts and 1 paper
as well as receive an award for my research at the
American Society of Clinical Pharmacology and
Therapeutics.
Is research hard in general?
The one thing no one will ever tell you about research is
that you are more likely to run into failures than
successes. I think that is why when people first try to
learn what research is, most of the time they get
discouraged and quit. People expect research to be easy
but what they do not know is research takes an immense
amount of time, resilience and of course, passion. There
will always be at least a one-year lag time between what
is currently being done in the lab and what is published.
It takes a lot of perseverance to conduct research and if
it is something you feel happy while doing, I would
recommend it to anyone. Do not do research if you are
just going to put it on your CV. It is obvious to anyone
when you are doing it as a check on your to-do list.
Xenleta (lefamulin): A Newly
intravenous Xenleta to 7-10 days of moxifloxacin with or
without linezolid. The second trial (LEAP 2) compared 5
days of oral Xenleta to 7 days of moxifloxacin. LEAP 1
showed intravenous Xenleta had similar efficacy to
moxifloxacin with or without linezolid. LEAP 2 showed
oral Xenleta, with two less days of therapy, had similar
results to moxifloxacin.2

Approved Drug for CABP
Reba Doohkie and Deanna Cordero Da Silva
Xenleta is an empiric pleuromutilin antibacterial used in
the treatment of community-acquired bacterial
pneumonia (CABP) in adults caused by Chlamydophila
pneumoniae, Haemophilus influenzae, Mycoplasma
pneumoniae, Streptococcus pneumoniae,
Staphylococcus aureus (methicillin-susceptible isolates),
and Legionella pneumophila. Xenleta is available in oral
and IV dosage forms, effectively used as monotherapy. It
should only be used to prevent or treat infections which
are expected to be caused by susceptible bacteria listed
above.3
Avoid giving medication to patients with known QT
prolongation, ventricular arrhythmias and patients
receiving medications which prolong QT intervals.
Lefamulin may cause fetal harm when administered to
pregnant women. There is no data on Xenleta in human
milk nor its effects on breastfed infants, but due to
potential adverse reactions, a woman should pump and
discard human milk during the treatment and for 2 days
after the final dose. Xenleta should also be avoided when
using strong CYP3A or P-gp inducers and inhibitors.3
According to the Center for Disease Control and
Prevention, around one million patients are hospitalized,
and fifty thousand patients die each year due to CABP.
Although it has been shown to be effective in clinical
trials, please use caution when prescribing or
administering Xenleta. Available in 150 mg/15 ml vials
and 600 mg tablets, this product offers dosing flexibility
that may shorten the patient’s treatment and hospital
stay duration.4

As a systemic pleuromutilin antibacterial, it works by

inhibiting bacterial protein synthesis through interaction
of hydrogen bonds, Van der Waals forces and
hydrophobic interactions with the A- and P-sites of the
peptidyl transferase center in domain V of 23s rRNA of
the 50S subunit. The bacterial ribosome binding pocket
closes around the mutilin core causing an induced fit
which prevents correct positioning of tRNA. This
mechanism of action lowers the chances of developing
resistance to other antibiotic drug classes, including
fluoroquinolones, glycopeptides, macrolides, β-lactams
and tetracyclines. The most common side effects for the
injections are administration reactions, hepatic enzyme
elevation, nausea, hypokalemia, insomnia and headache.
As for the tablets, the most common side effects include
diarrhea, nausea, vomiting and hepatic enzyme
elevation. Adverse reactions include QT prolongation
and Clostridium difficile-associated diarrhea.1

Xenleta was evaluated in two clinical trials with a total of

1,289 patients. They were split into two groups; 641
given were Xenleta and 641 were given a comparator
drug. The first trial (LEAP 1) compared 3 days of
 References
1. Center for Drug Evaluation and Research. “Drug
Trials Snapshots: XENLETA.” U.S. Food and Drug
Administration, FDA, 4 Sept. 2019,
www.fda.gov/drugs/resources-information-
approved-drugs/drug-trials-snapshots-xenleta.
2. Commissioner, Office of the. “FDA Approves New
Antibiotic to Treat Community-Acquired Bacterial
Pneumonia.” U.S. Food and Drug Administration,
FDA, 19 Aug. 2019, www.fda.gov/news-
events/press-announcements/fda-approves-new-
antibiotic-treat-community-acquired-bacterial-
pneumonia.
3. Nabriva Therapeutics. “Xenleta (Lefamulin).” Xelenta
(Lefamulin), Nabriva Therapautics, 2019,
www.xenleta.com/?gclid=CjwKCAjwldHsBRAoEiwAd
0JybRPGMSP4ZZmpk28fyKK4hVc75VoLqD-
RaESgjRkOUsfGPWtm6CYNLxoCiwYQAvD_BwE.
4. Voelker R. New Antibiotic for Community-Acquired
Pneumonia. JAMA. 2019;322(13):1246.
doi:10.1001/jama.2019.15179
A Nontraditional HIPPE Rotation
Reba Doohkie
For my HIPPE rotation, I was placed with an IT
pharmacist. Of course, I did choose this as one of my
choices when I was given the opportunity to rank each
rotation within my location. I didn't think I'd learn as
much as I did when I ranked this option. I'm so glad I did.
On my first day, I was overwhelmed by all the different
software programs used by the facility. I thought I'd
never get the hang of it. There were long instruction
manuals, specific login information for each website and
even excel sheets which needed to be updated with
information from other websites. My preceptor calmly
showed me how to use each of the programs and what
they were for. He even showed me a little bit of coding!
As an IT pharmacist, my pharmacist isn’t required to
code, but he does it to help improve the functioning of
software programs used within the pharmacy and
hospital. I was able to speak to technicians, residents,
and some pharmacists about their experiences and what
they would like to see improved within the software
programs. After a week and a half, I felt confident
enough to work on my own. He gave me the
responsibility of choosing what to work on and what time
to do so. Each day, I would let him know what my
progress is and where I'll start the next day. He started
calling me "boss" due to my independent and
authoritative nature.
During the days my preceptor wasn't available or
whenever I had free time, I shadowed other pharmacists
and completed my workbook assignments. I highly
suggest completing the workbook and presentation early
so you can use the rest of your time for learning. Some
students switched days on their specific unit with me so
I was able to see what the specialists do. Occasionally,
some pharmacists would request our HIPPE student
group to help with simple tasks. I enjoyed the moments
spent with classmates, labeling syringes and talking
about our unique experiences. I also made tutorials to
help guide the new residents through the pharmacy’s
software programs and utilized their feedback to help
improve the tutorials. Another cool accomplishment was
being able to create pivot charts for computer user data.
This meant I gathered data from the laptops used by
pharmacy personnel and input that data into an excel
sheet to create pivot charts which were then sent to my
pharmacist’s manager. I cleared the queues of a drug
waste tracking program and for the charge on
administration program. Whenever there was an issue
on the nurse’s or pharmacist’s end, I contacted them for
clarification by calling or emailing them. I learned not
only about this nontraditional pharmacist role, but also
about time management, project management, and
communication skills. I felt accomplished by the end of
my rotation.
Awesome HIPPE students from my rotation site.
Looking forward, I know I won't be as experienced as
every other student out there during fourth year
rotations, but I also learned something they didn't. It was
exciting to try something different and I'll still be able to
have that clinical experience in my APPEs. My advice for
other students is to go out and learn something new. Ask
your preceptors if you can shadow other pharmacists in
different settings at your location or even other locations
within the same hospital system. Use your days off from
school to shadow professors who are in an interesting
field, especially during summer, spring, and winter
breaks. You have nothing to lose and everything to gain.
Who knows, you may even find your dream job.
Diabetes Management Updates 2019
Christian Alvarez
The American Diabetes Association has updated its
guidelines in multiple areas of diabetes management.
Though the ADA is very important source of information
for multiple healthcare professionals, it is advised that
pharmacists consult the ADA annually as many updates
are in drug therapy and lifestyle modifications.
Pharmacists have a duty to continue to stay up to date
on new evidence in order to utilize it to improve the
outcomes and quality of life of diabetic patients.
One of the updates discussed extensively was ideal
nutrition for adults who have pre-diabetes or type II
diabetes. Evidence from the literature has shown there
is not a set percent of calories, carbohydrates, and
protein for people with diabetes. Pharmacists should
encourage diabetic patients to add the following
suggestions to help improve their current diet: no
starchy vegetables, reduced refined sugars and grains,
and select whole foods over processed foods. The
Mediterranean-style diet, a plant-based and low
carbohydrate diet, has been shown to have benefit for
one’s health; however, it is important to discuss with the
patient with regards to their preferences and goals.
Studies have shown reducing carbohydrate intake has
also been beneficial to improve overall health; however,
there have been issues with maintaining low-
carbohydrate diet for an extended period. If a patient is
interested in a low-carbohydrate diet, it is important to
regularly reassess and individualize meal plans tailored
to patient’s carbohydrate goal. A low-carbohydrate diet
is not recommended in pregnant or lactating women,
people with renal disease, and patients who are on SGLT-
2 inhibitors due to increased risk of ketoacidosis.3
Weight loss was another topic discussed in-depth. In pre-
diabetic patients, the goal weight loss is 7-10% of their
body weight to reduce the risk of developing type II
diabetes. Weight-loss medications can be utilized to
assist patients to lose weight and maintain the weight
loss. For overweight and obese patients, a 5% loss of
weight is the minimum necessary to see improvements
in glucose and blood pressure measures. Since greater
weight loss is associated with greater clinical benefit, it is
encouraged to push a weight loss goal of 15% if it is safe
and feasible for the patient. Maintaining weight loss for
5 years, though a very challenging task for many patients,
has been shown to improve both A1C and lipid panels.3
Since cardiovascular disease is a common comorbidity in
diabetic patients, it is important to improve
cardiovascular outcomes with pharmacotherapy. The
ADA has added icosapent ethyl, brand name Vascepa, to
treat severe hypertriglyceridemia and prevent
cardiovascular death in statin-treated diabetic adults.
This is based on the REDUCE-IT Trial, which enrolled 8179
patients and showed a composite relative risk reduction
of nonfatal myocardial infarction, stroke, and
cardiovascular death by 26%. Other fish-oil products
have not been evaluated to test their effectiveness in
reducing cardiovascular outcomes. In the Researching
Cardiovascular Events with A Weekly Incretin in Diabetes
(REWIND) trial, dulaglutide, a GLP-1 agonist, has been
shown to have macrovascular benefits including risk
reduction in nonfatal myocardial infarction, stroke, and
cardiovascular death.1
The ADA has implemented recommendations with
reducing the complexity of insulin use in the geriatric
population. Intense therapy for a tight glycemic goal has
shown less benefit and more risk, especially the risk of a
hypoglycemic episode most notably in the elderly
population. Deintensification of insulin may be utilized in
older patients to combat difficulties of self-management,
reducing medical costs, and decreasing the risk of
hypoglycemia. Figure 1 can be utilized to assist clinicians
with regards to simplifying insulin regimens for elderly
patients. The figure should be utilized based on the
individual’s specific glucose goals.2

Figure 1
References
1. American Diabetes Association. “10. Cardiovascular
Disease and Risk Management: Standards of
Medical Care in Diabetes—2019.” Diabetes Care,
vol. 42, no. Supplement 1, 2018, doi:10.2337/dc19-
s010.
2. American Diabetes Association. “12. Older Adults:
Standards of Medical Care in Diabetes—2019.”
Diabetes Care, vol. 42, no. Supplement 1, 2018,
doi:10.2337/dc19-s012.
3. American Diabetes Association. “5. Lifestyle
Management: Standards of Medical Care in
Diabetes—2019.” Diabetes Care, vol. 42, no.
Supplement 1, 2018, doi:10.2337/dc19-s005.
New Areas of Collaborative Practice
Pamela Tabowei
While there are few studies which have studied the
impact of interprofessional collaborative practice on
specialty care outcomes, it is imperative not to dismiss
the ability of specialty pharmacists to create an indelible
mark on specialty care outcomes. The goal of
collaborative practice is centered on transforming the US
healthcare system and to do this, it is necessary to
improve healthcare costs, access and outcomes. This is
where pharmacists, including specialty pharmacists, can
bring in their collective expertise to team based or
multidisciplinary care.
Clinical pharmacy specialists are the most accessible and
have the schedule capacity to meet with patients more
frequently and to work intensively on one or more health
problems that could be recurring.1 According to the CDC,
chronic disease is the leading cause of death and
disability in the United States2 and more often than we
think, chronic diseases require specialty care. Therefore,
incorporating specialty pharmacists or clinical
pharmacists into collaborative practice would lead to
personalized, timely, and empowered patient care. Not
only that, it will build trust between specialty
pharmacists and other members of an interprofessional
team. Building this team approach or collaborative
practice will mean engaging physicians in what is called
collaborative practice agreement (CPA).3
The Centers for Disease Control and Prevention (CDC)
has defined CPA as a foundation of trust which is built
between pharmacists and physicians and this will allow
for increased efficiency between members of a team
providing patient centered care, reduced healthcare
costs, and promotion of better healthcare outcomes.
Unfortunately, CPAs are defined differently according to
the laws proposed by each state, and this can impact
what a clinical pharmacist can or cannot do.
CPAs are allowed in 48 states, although the scope of
services and conditions for collaboration varies among
states. Some states require CPAs to be between one
pharmacist, one prescriber, and one patient, while
others provide broad authority—such as that in
Washington, where a prescriber can enter a singular CPA
with multiple pharmacists covering care for multiple
patients.1
Realizing team-based care might not be the same in each
state, and that it is important to consult the laws
pertaining to CPAs, the CDC has come up with a template
which can be dictated to the preferences of state laws.
The CDC also has provided a resource guide which will
provide implementation of a newly construed CPA which
could include registering with a state board of pharmacy
or some governing body.
There are several areas of specialty care which could use
the collaborative expertise of a clinical pharmacist, some
of these include transitions of care, ambulatory care,
geriatrics, psychiatry, emergency medicine, intensive
care unit and antimicrobial stewardship. Each area of
specialty care caters to the Institute of Medicine (IOM)
core goal of providing quality patient care and reducing
medication errors.
As interest for collaborative practice between
pharmacists and members of an interprofessional team
grows, there is room for new areas of collaborative
practice to come up as well as the possibility of
pharmacists to be seen in a different light as providers
and not just dispensers of medications. The road ahead
is promising, and as student pharmacists we can carve
our niche in collaborative practice following graduation
and getting licensed if we are more than willing to be
open to what is out there in the pharmacy world.

References
1. Amy K. Erickson. CPAs cement trust for physician–
pharmacist collaboration. APhA. Pharmacy Today
2016;22 (8): 44-47
2. Centers for Disease Control and Prevention. Chronic
disease overview. Chronic diseases: the leading
causes of death and disability in the United States
website.
http://www.cdc.gov/chronicdisease/overview/index
.htm.
3. Centers for Disease Control and Prevention.
Advancing Team-Based Care Through Collaborative
Practice Agreements: A Resource and
Implementation Guide for Adding Pharmacists to
the Care Team. Atlanta, GA: Centers for Disease
Control and Prevention, U.S. Department of Health
and Human Services; 2017. Retrieved 10/11/19 from
https://www.cdc.gov/dhdsp/pubs/docs/CPA-Team-
Based-Care.pdf
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