Evolving Patient Care: The Pharmacists’ Role

1. Evolving Patient Care: The Pharmacists’ Role Jessica Haskins-Cummings, PharmD Pharmacy Manager, Walgreens

2. Objectives Describe current trends in the pharmacy profession Explain the development of pharmacists and their evolving role in a multi-disciplinary patient care team Describe community pharmacy consultations and what pharmacists are discussing with your patients Discuss new medications and regulations

3. Pharmacy Past

4. Pharmacy Present

5. ‘Well Experience’ model

6. Pharmacy Future

7. Pharmacy Future More multidisciplinary team approach to patient care Reimbursement based on outcomes and readmission rates Clinical services outside of traditional pharmacy practice Personalize and optimize therapy

9. Path to PharmD • All PharmD graduates now • Basics still there: medicinal chemistry, pharmacokinetics, pharmaceutics, pharmacodynamics • 2 years pre-pharm, 4 years pharmacy school • Residency and fellowships are more common • Multidisciplinary professional development throughout school (longitudinal assessment) • AACP and ACPE accreditation standards • Extern-type rotations throughout school • More direct patient contact • More interaction with different facets of the healthcare system

10. Path to PharmD Graduates expect more from the workplace in clinical, retail, hospital, and specialty pharmacy • Private consultation/ immunization rooms • Clinical decision making in rounds • Clinical services: • health testing • Medication Therapy Management • immunizations • specialty drug therapy

11. More involvement in patient care • Bedside consultations before discharge • Reassurance and integrating new therapy to current lifestyle • Retail ‘window’ consults • Balance of optimal therapy, lifestyle changes, insurance limitations, and customer service • Comprehensive Medication Therapy Management (MTM, ‘brown bag’ consult) • Thorough sit-down therapy optimization

12. Counseling your patients

13. Adherence • $100 billion per year in hospital admissions due to poor medication adherence. • Percentage of patients with chronic illness that DO NOT take medications as prescribed: 40-50% • 22% take less than the amount prescribed • 2/3 do not take any of their medication, but fill them • 12% do not even fill their prescriptions

14. Disease state specific counseling • Diabetes Mellitus: • Severe hyperglycemia with insulin resistance, ketoacidosis • Increased risk for gum disease and tooth decay • Blood disorders: Leukemia, sickle-cell anemia • Increased risk of gingivitis • Immunocompromised patients: Sjorgen’s syndrome, viral infections • Increased risk for oral disease • Pulmonary conditions: TB, purulent infections, tonsillitis, rhinitis • Increased risk for halitosis • Renal or hepatic failure • Increased risk for gum disease and tooth decay

15. Pre-op Regimen Oral Antithrombotics Anticoagulants Coumadin, Jantoven (warfarin) Eliquis (apixaban) Pradaxa (dabigatran) Xarelto (rivaroxaban) Antiplatelets Aspirin Effient (prasugrel) Brilanta (ticagrelor) Plavix (clopidogrel) Antibiotic prophylaxis • Controversial in recommendations • Case-by-case situations • Pharmacist role • Proper timing of therapy • Side effects and how to minimize • Monitoring for interactions and allergic reaction history

16. Surgery Meds • Anesthesia/ Sedation • Anti-anxiety • Anti-inflammatories • Pain relievers • Mepergan Fortis: no longer available • FDA & DEA request to have hydrocodone reclassified to a scheduled 2 controlled substance

17. Hydrocodone/APAP combo

18. Hydrocodone/APAP combo

19. Maintenance Products • Muscle relaxers & anti-inflammatories • Rx Only fluoride supplements • >1500 ppm total fluorine • OTC prevention: • Stannous fluoride: inhibits bacterial growth • Triclosan: inhibits prostaglandins • Artificial saliva products (Salivart)

20. Meds that affect oral health • Chemotherapeutics, immune modulators, head / neck radiation therapy • Oral mucosal symptoms delayed after therapy • Preventative therapy warranted: chlorhexadine rinse, sucralfate suspension, allopurinol mouthwash, strict adherence to oral care regimen • Amifostine (Ethyol) concomitant therapy – scavenger of free radicals • Oral pilocarpine – stimulates salivary secretions

21. Meds that affect oral health • Anticholinergics • oxybutinin, diphenhydramine, dicyclomine, atropine • Antidepressants • amitriptyline, doxepin, desipramine • Diuretics • hctz, furosemide • Stimulants • pseudoephedrine • Antipsychotics • chlorpromazine, thioridizine, clozapine Decreased saliva flow Increased risk for gingivitis & halitosis Typically dose related

22. Meds that affect oral health • Procardia, Nifedical(nifedipine) • Overgrowth of gums onto teeth • Sandimmune (cyclosporine) • Swollen, painful, red gums • Dilantin (phenytoin) • Swelling, bleeding of gums • Inhaled corticosteroids (Advair, Qvar, Flovent) • Increased risk for thrush • Bisphosphonates • Osteonecrosis (IV 94% vs oral 6%)

23. OTC medications – what are your patients finding at their drugstore? • Fluoride products • Topical anesthetics • Peroxide & pain-relief washes • Dry mouth products • Nightguard • Filling repair kits • Whiteners • Floss • Sensitivity products • Denture products • Dental wax

24. New Developments in medicine • Myrbetriq: overactive bladder • Sores, ulcers, or white spots in the mouth or on the lips • Dry mouth • TudorzaPressair: bronchodilator • Dry mouth • Fruit-like breath odor • Zetonna: allergic rhinitis • White patches inside nose or throat

25. Multidisciplinary approachto patient care Improve adherence Improve outcomes Improve quality of life

26. jessica.haskins@walgreens.com Thank you!!!