Let’s Make 23 the GOAT!
Greatest. Of. All. Time.
Whenever a columnist wants to stir up some lively conversation, they can pull out the question: “Who is the G.O.A.T.?” For example, there are several basketball players you could argue to be the greatest of all time. Chamberlain. Olajuwan. Byrd. Johnson. LeBron. Kobe. If you ask me, I grew up in Illinois, watching the Bulls win 6 championships, so of course I think that Jordan is the GOAT. Michael Jordan immortalized the number 23, so I think that we should make ’23 the Greatest Year of All Time.
How would we do that? A good start would be to sign up for the Spring Meeting, invite a colleague to join MSHP or get involved with a committee, and ask for April 5th off so that you can attend Legislative Day. Let’s take some lessons from Jordan for how we can make this year amazing.
Whether you are working on MSHP initiatives or on a patient care issue at work, we have to stay focused. There are so many distractions in the ‘whirlwind’ of daily life that it is easy to lose sight of our big goals. This can lead to discouragement and burnout. It can also lead to delays and disruptions. At MSHP we need to stay focused on our biggest goal this year: inviting more people to become members, and inviting our members to get involved.
Love him or hate him, no one questioned Jordan’s work ethic on the court. At practice, in games, and even in exhibition games, he worked hard. He pulled off one of his legendary wins while sick with the flu (Infectious Disease Protocols anyone???), and he wasn’t willing to sit on the sidelines, despite the barriers. This is a challenging time to be in healthcare and we are all working very hard. I am so grateful to the many leaders who volunteer their time and energy to make MSHP what it is! MSHP is made up of some hard working people!
Jordan was not necessarily the type of leader that I strive to be, and some of his personal attributes had negative consequences. But, he was always focused on making his teammates better so that they could win. As a team. For each of the 6 titles he won, he had a solid cast of teammates who played their role and helped the Bulls win. And keep winning. Jordan knew that he was the star and he could win games by himself, but he also knew that he could not win championships if his team wasn’t working together. In the last newsletter I discussed how we are better together, and if we are to make 2023 the best year ever, we have to get there as a team.
How About Those Chiefs?!
As the Chiefs make another run to the big game, we get to watch as Mahomes is earning the right to be included in that conversation. He’s not there yet, but he works hard so that every game can be evidence of his greatness. Let’s stay focused, work hard, and grow as a team as we make 2023 our best year yet!
The MSHP R&E Foundation continues to offer innovative and meaningful educational and speaking opportunities for our membership!
Year two of our Virtual Grand Rounds series is underway, with multiple offering each month!
Detailed information can be found here.
The Preceptor Development Series will continue into 2023 with quarterly programming for preceptors of all levels throughout our state.
ASHP Midyear Clinical Meeting Missouri Reception
Thank you for all who were able to attend and who participated in the fundraising activities made available during the reception.
Spring Meeting Update
We are looking forward to our spring meeting activities and awards. We will be announcing winners of our annual awards (Best Practice, Tonnies’ Preceptor of the Year, and Garrison).
We are also finalizing the plans for a social event for Friday night of the Spring Meeting. Please join us for BINGO night; details and pricing to come shortly. Please check the MSHP website for information.
I wish you all heath and joy in the new year!
Tony Huke, Pharm.D., BCPS
MSHP R&E Executive Director
Call to Advocacy
By: Annie (Stella) Kliewer
In September 2022 ASHP had their legislative day in Washington D.C. Soon after ASHP asked all of their affiliate associations to reach out to their U.S. Congress members in support of each of the following bills:
· H.R. 7213 - Equitable Community Access to Pharmacist Services Act
o Would allow Medicare patients access to various treatment and testing services that pharmacists are licensed to provide and allow pharmacists to respond to ongoing and future public health threats
· H.R. 4390 - Protect 340B Act
o Bipartisan legislation prohibiting discriminatory policies against 340B providers by a PBM, group health plan or other entities
· H.R. 1384/S.445 - Mainstreaming Addiction Treatment Act included in Restoring Hope for Mental Health and Well-being Act of 2022.
o This bill would eliminate the need for an X-waiver, increasing access to medications for opioid use disorder for patients who struggle with addiction
· Protect Funding for Pharmacy Residency Programs
o CMS has been clawing back funding from many health-system affiliated residency programs.
o CMS is alleging that standard hospital business and training practices violate its requirements for residency programs but lack guidance on this issue thus many programs do not know how to proceed in order to retain funding
o Ask: Request that your congressional offices ask CMS to suspend cost disallowances until the agency provides guidance answering questions surrounding residency compliance.
MSHP would greatly appreciate you reaching out to your U.S. Congress member regarding the above issues. You can find who your legislator is here. At the link to find your legislator, it will also have a contact button listed. Please reach out to your legislators using that link!
The MSHP Public Policy Committee did not create a form letter as often legislators will toss form letters in the trash because it isn't a personal message from a constituent. A message to your legislator doesn't have to be long but it being personally written by you will go a long way! Here you will find the leave-behinds that ASHP provided to members at ASHP Legislative Day so feel free to send that with your email or use it to draft your email to them. The more of us from the state of Missouri reaching out the better chance of our voices being heard!
Year two of our Virtual Grand Rounds series underway, with multiple offering each month!
We are pleased to announce that the MSHP R&E Foundation will be recognizing the Missouri representatives for the ASHP Clinical Skills Competition during our reception.
Trevor Hall and Jacob Mozer
Emily Stevenson and Kristen Ritchie
MSHP R&E Foundation Fundraising as ASHP
We will be selling drink ticket packages onsite that will allow for a small donation to be passed along to the R&E Foundation, while you enjoy a beverage with colleagues and friends.
Additionally we will be selling raffle tickets for two different groups of prizes.
High stakes tickets will be $5 each or 5 tickets for $20.
High stakes prizes will consist of larger denomination gift cards and $100 in chips to Mandalay Bay
Lower Stakes tickets will be 5 tickets for $5
Lower stakes prizes will consist of smaller denomination gifts cards and $25 in chips to Mandalay Bay.
The MSHP Spring meeting call for poster and awards will be distributed in the very near future. Our deadline for submission is scheduled for Tuesday January 10th, 2023. Please consider nominating a deserving member for one of our awards. Additionally, encouraging students, residents, and pharmacists to submit their work as a Poster or for our Best Practice Award. It is wonderful to share the high-quality work our members implement on a daily basis with the entirety of our membership and that of ICHP, through this education opportunity!
Bundle up as the cold weather is upon us and please have a wonderful Holiday Season!
Public Policy Update
Over the past several months the Joint Oversight Task Force for Prescription Drug Monitoring has been working to develop and operationalize a Missouri state prescription drug monitoring program (PDMP). The Public Policy committee recently conducted a MSHP member survey to gather input and provide feedback directly to this task force. The goal of the survey was to identify and communicate the priorities of MSHP members with regard to a MO state-wide PDMP. A majority of respondents (91%) agreed that the PDMP should have full integration within the electronic health record (EHR). The survey collected a list of the most common EHRs utilized by members for the taskforce, to aid them as they evaluate vendors for this capability. MHSP members also voiced that the PDMP should have interconnectivity between all 50 states. A PDMP with a high level of interconnectivity would be advantageous in a state like Missouri, which shares its border with eight different states. The survey also identified some functionality of the current Saint Louis County PDMP that worked well that would ideally be carried forward in the MO state PDMP. The Public Policy Committee shared the comments and data collected in the survey directly with Joint Oversight Task Force for Prescription Drug Monitoring. Additional discussion on the PDMP and other exciting topics will continue in the monthly Public Policy Committee meetings.
The MSHP R&E Foundation continues to offer innovative and meaningful educational and speaking opportunities for our membership! For the 2022-2023 year we will be continuing our Preceptor Development and Virtual Ground Rounds series.
The Virtual Grand Rounds series planning is well underway, please see the links and information below!
Peer Reviewer sign up: https://www.surveymonkey.com/r/F6M7PGH
- Peer reviewer will be matched with a resident who is presenting on a topic within the peer reviewer’s practice area
- Resident will send the peer-reviewer their presentation at least 21 days prior to the presentation date
- Peer reviewer will review and send back edits / provide guidance and expertise on the topic
- Goal: provide the resident with a review from a practice expert outside of their own institution (and provide a networking opportunity too!)
Moderator sign up: https://www.signupgenius.com/go/10C0D4CA8AD2AA0FCC43-grand
- Moderator will be provided a script prior to the day of the presentation
- Moderator will call into the presentation (all presentations will be virtual) and introduce the presenter and moderate the hour-long presentation including Q&A and providing the link for assessment questions and evaluation in order for participants to obtain ACPE CE
New for the 2022-2023 Virtual Grand Rounds Series we are happy to announce the availability of ACPE CE credit!
The Preceptor Development Series continues with quarterly programming for preceptors of all levels throughout our state.
Upcoming Preceptor Development events include:
November 17th, 2022, in collaboration with KCHP, a panel discussion touching on various topics including pharmacist burnout, stress and attrition.
Winter 2022-2023 dates, TBD, a discussion with Panelists Ashley Duty, Sarah Mester, and Megan Rech covering Resilience in Pharmacy
Lastly, we are working on fund raising opportunities to hold during our Missouri state reception at the ASHP Midyear Clinical Meeting.
As always, if you are able, please donate to the R&E Foundation here: https://www.moshp.org/donate
Have a wonderful start to your fall season!
Tony Huke, Pharm.D., BCPS
In my previous article, I talked about the importance of investing in our personal growth and in the growth of those around us. Today, I am going to review the ways that I want to see MSHP grow as an organization!
Advancing Pharmacy Practice
Our patients need us now more than ever, so we need to grow in the way that we provide for them. That means that we need to continue to advance laws and rules that will get rid of the barriers between us and the patient. And equally important, we need to grow our ability to actually provide that care. As an example, Medicaid has many opportunities right now for us to provide direct patient care and receive compensation. Are you taking advantage of that? What about Medication Therapy Services? Current law allows a pharmacist to create an agreement with a physician to provide direct patient care. We would like to see those statutes simplified, but until they are changed are you making use of what is allowed? Did you know that technicians are allowed to check the work of other technicians, thus freeing up pharmacists to provide better services to our nurses, doctors, and patients? Did you know that you can send home inhalers and topical products at discharge? All of these things are available today. Most of us are not operating at the top end of our license and training today, and so we should make the extra effort to care for our patients in ways that are currently allowed. If we do that, we will be ready for even more growth when Medicare Provider Status is granted. Right now, we need to continue to grow ourselves so that we will be ready for this new responsibility.
Expanding Our Influence
In order for that to happen, we need to continue to grow our influence. We need to spread the word about MSHP and enroll new members. Word of mouth is the most effective advertisement, so please talk about MSHP with your coworkers, and persuade them to join. We need to continue to build solid relationships with the Missouri Pharmacy Association, the Missouri Hospital Association, and with other leaders across the state. We also need to continue to build on the excellent work that has already been done in collaboration with the Board of Pharmacy and regulators and with our elected officials in Jefferson City. Everyone wins when we grow those relationships.
Let’s continue to grow our influence across the state as an organization and learn how to grow in our direct patient care opportunities that are available to us now. It's my hope that MSHP will serve as a catalyst for growth in these four areas.
Thank you again for granting me the opportunity to serve as MSHP president this year. I look forward to growing with you. -Note: this contains excerpts from the Presidential inaugural address delivered at the 2022 MSHP Spring Meeting
Safety and Efficacy of Anticoagulation Regimens in COVID-19
By John Love, Pharm.D, MBA
Program Number :
Approved Dates: April 1, 2022-October 1, 2022
Approved Contact Hours: One Hour(s) (1) CE(s) per session
Medically ill patients are at an increased risk of development of venous thromboembolism (VTE). Guidelines have historically made recommendations for prophylactic anticoagulation when patients are acutely ill1 and therapeutic anticoagulation when there is confirmation of deep venous thrombosis or in select situations, such as in atrial fibrillation2. Anticoagulant options include low molecular weight heparin (LMWH), unfractionated heparin (UFH), fondaparinux, direct oral anticoagulants (DOACs) such as apixaban or rivaroxaban, argatroban, or bivalirudin.
In 2019, a novel coronavirus (COVID-19) was discovered which has since become a global pandemic. Early in the pandemic, it was observed that patients acutely ill with COVID-19 were at increased risk of development of VTE. Patients that are hospitalized with COVID-193 are thought to be in a pro-thrombotic state due to increased fibrin deposits, reduced natural anticoagulation (or maximal anticoagulation being reached), an increase in interleukin 1-b and interleukin 18. A recent meta-analysis found that the incidence rate of VTE among COVID positive pateints to be 14.7%4. Unsurprisingly, administration of anticoagulant medications was associated with improved mortality5. However, the optimal regimen for prophylactic anticoagulation was unknown and has since been the objective of many studies.
The International Society of Thrombosis and Hemostasis (ISTH)6, the American Society of Hematologists (ASH)7, and the National Institute of Health (NIH)8 have each produced guidelines that reviewed anticoagulation research in COVID-19. Both ISTH and ASH recommend the use of prophylactic anticoagulation over therapeutic or intermediate dose anticoagulation due to limited data. However, both of these guidelines were published before larger, randomized clinical trials were published that have provided more insight.
The NIH guidelines initially made a similar recommendation but were updated as more data was published. The NIH guidelines currently recommend therapeutic anticoagulation in patients who are hospitalized, require low-flow oxygen, and do not require intensive care unit level of care and have an elevated D-dimer level above the upper limit of normal. Therapy should continue for fourteen days or until discharge, whichever comes first. Based on the results of more recent studies, the NIH recommends against the use of therapeutic anticoagulation in patients requiring intensive care unit level of care or high-flow oxygen. It should be noted that this recommendation is without confirmation of DVT or PE. The NIH does not recommend routine imaging for DVT or PE unless the patient is experiencing symptoms consistent with those conditions. Unless a contraindication exists, the NIH recommends prophylactic dosage anticoagulation in all patients who are not receiving therapeutic anticoagulation.
The NIH identifies contraindications to therapeutic anticoagulation as those with platelet counts < 50 x 109/L, hemoglobin < 8g/dL, requiring dual antiplatelet therapy, major bleeding within 30 days that required a visit to an emergency department or hospitalization, history of a bleeding disorder, or an inherited or active acquired bleeding disorder. This list of contraindications was developed based upon exclusion criteria from the major studies that evaluated the use of therapeutic anticoagulation.
The NIH guidelines also recommend the use of LMWH as first line therapy, UFH as second line, and recommends against the use of direct oral anticoagulants. This recommendation stems from the shorter half-lives of these agents, the relative ease of bleeding reversal, that these agents have intravenous and subcutaneous administration methods (which may be beneficial in patients who are unable to tolerate oral medications due to oxygen requirements), and are noted to have less drug-drug interactions compared to direct oral agents.
The NIH guidelines are based on four randomized trials that together helped identify which patients would benefit most from therapeutic anticoagulation. The ATTACC, ACTIV-4a, and REMAP-CAP investigators combined their results for publication in two of these studies. One study of these studies reviewed non-critically ill patients (defined as those not requiring intensive level care or high-flow oxygen), while the other looked at critically ill patients. The HEP-COVID trial evaluated critical and non-critically ill patients, while the RAPID trial evaluated patients who were started upon anticoagulation shortly after admission.
Therapeutic Anticoagulation with Heparin in Non-Critically Ill Patients with COVID-1910 This is the comparison study published by the ATTACC, ACTIV-4a, and REMAP-CAP investigators that focused on patients who were not yet critically ill. This study included many patients, with a population size of 2219 patients. The included patients were considered non-critically ill, which was defined as being hospitalized without requiring ICU level care (including high-flow oxygen) at enrollment. Again, this study aimed to evaluate the impact on organ support-free days, but also included a stratification based upon D-dimer level at two times the local upper limit of normal for each institution. The primary outcome was designed to analyze the number of days without requiring critical care level organ support.
The final results are included below with a comparison to the data found in critically ill patients, as well as reporting the d-dimer stratification. This study was stopped early due to meeting predefined criterion for superiority for therapeutic anticoagulation, but it is important to note that the pre-defined primary outcome of organ support-free days up to day 21 had to be changed to survival to discharge without requiring intensive care level of organ support as the average organ support-free days in both groups was 22 days (and the outcome was designed to stop counting at 21 days). The authors calculated that for every 1000 patients that received initial treatment with therapeutic anticoagulation, 40 additional patients would not require organ support from addition to discharge. This would come at the expense of 7 additional major bleeds.
The RAPID trial was a multicenter trial that was evaluating the impact of therapeutic dose anticoagulation compared to prophylactic dose when therapy is started early in the disease course, which the study defined as within five days of admission. The RAPID trial only evaluated UFH and LMWH. The primary outcome was a composite outcome defined as death, invasive mechanical ventilation, non-invasive mechanical ventilation, or ICU admission and was not statistically significant. However, this study did not meet power. Unlike the other trials included in this review, this study did not find a benefit in escalation of care but did find a mortality benefit when the composite outcome was broken out into individual components.
“When you can’t find the sunshine, be the sunshine.”- Unknown
“If you do something awesome, you should be proud of yourself.”-Damon Lindelof
“To plant a garden is to believe in tomorrow.” - Audrey Hepburn
Whew, what a year it has been!! As I reflect upon this past year, I cannot help but be overwhelmed by the continued resiliency and dedication displayed by our members.
I am so proud of what we were able to accomplish together as an organization. Throughout the year, there were more educational sessions offered than ever before. As a board, we voted to form two new committees, a Diversity, Equity and Inclusion Committee and a Dues Committee. Both committees will focus on what we can do better as an organization to provide for the needs of our members. In early April, we had a good turnout at Legislative Day. In late April, we had another successful Spring Meeting, providing 20 hours of hours of CE to our members and recognized many of our colleagues for their contributions to the profession.
During my final address at the Spring Meeting, I spoke about thankfulness. Thank you to Laura, Sara and the rest of the Newsletter Committee for the amazing newsletters you continue to put out. Thank you to our Board members for all the time and effort that you have put into this organization over the past year. Thank you to my employer, CoxHealth, for their continued support of my work with MSHP. Thank you to my kids for your understanding about my time away. And thank you to all members of MSHP for trusting in and supporting us as an organization.
A special shout out to Davina for your outstanding run on the presidential team! Best of luck to Nathan as you take the reins this next year! Finally, welcome Sayo to the presidential team!
This will be my last call out to members for you to be on the lookout for opportunities to get more involved with MSHP through committee and board memberships. It takes a small army of willing volunteers to keep this organization successful. Please do not hesitate to reach out to any current board members if you have any interest or questions.
I hope all of you have an amazing summer and am grateful to you all for this opportunity!!
Christina Stafford, PharmD, BCPS
Author: Emily Stock, BS, PharmD Candidate 2023 – St. Louis College of Pharmacy at UHSP
Mentor: Paul Juang, PharmD, BCPS, BCCCP, FASHP, FCCM – Barnes-Jewish Hospital
Of all hospitalizations ending in death, sepsis is present in 30 to 50%. In the US, sepsis accounts for 250,000 deaths annually.1 According to the 2021 Surviving Sepsis Campaign International Guidelines for the Management of Sepsis, sepsis and septic shock are medical emergencies that necessitate immediate resuscitation and treatment.2 While many factors can be optimized in the treatment of sepsis, like use of antibiotics and appropriate monitoring parameters, the best choice of fluids for initial resuscitation has been debated. The 2021 Surviving Sepsis Campaign Guidelines provides an update to the 2016 recommendations on the choice of fluids in resuscitation.2
The Guideline again recommends crystalloid over colloid as the initial fluid of choice.2 Examples of crystalloids include normal saline, lactated ringers, and Plasma-Lyte. Examples of colloid fluids are albumin and, not widely used, hetastarch. Crystalloids are inexpensive and widely available which supports their use in sepsis. In addition, studies have shown there is no clear benefit of colloids over crystalloids.3In 2016, the guideline recommended either saline or balanced salt solutions for choice of crystalloid fluid for initial resuscitation in septic shock. The 2021 update now recommends balanced salt solutions instead of normal saline.2 Balanced salt solutions, like lactated ringers, have electrolytes in concentrations more similar to the serum and the extracellular fluid. This potentially reduces adverse effects related to the disruption of acid-base balance that can be associated with normal saline.4 Potential adverse effects of normal saline include hyperchloremic metabolic acidosis, renal vasoconstriction, increased cytokine secretion, and concern for acute kidney injury (AKI).5In a study evaluating fluid choice in a rat model of sepsis, volume resuscitation with the normal saline resulted in higher rates of kidney injury and acidosis compared to volume resuscitation with Plasma-Lyte.6
The scientific basis of the adverse effects associated with normal saline is related to its chemical makeup. There is 10% more sodium and 50% more chloride in normal saline compared to normal extracellular fluid (see Table 1).5 Based on this higher concentration of chloride, potassium can shift out of the cell in response to the hyperchloremic acidosis. Hyperchloremic acidosis can also increase inflammation via increase in inflammatory mediators. Hyperchloremia can result in renal vasoconstriction and reduced glomerular filtration rate. The acidosis and hyperkalemia that can be induced by normal saline can potentiate existing kidney issues in septic shock patients.
Besides the scientific argument for balanced crystalloids, there is some clinical evidence suggesting the benefit of lactated ringers over normal salinein regards to renal function and possibly mortality. The SMART trial in 2018 showed a lower incidence of major adverse kidney event within 30 days (MAKE30) with balanced crystalloids when compared to saline in critically ill adults. MAKE30 is a composite endpoint of death, new renal replacement therapy, or persistent renal dysfunction.7 Likewise, the SALT-ED trial showed a difference in the secondary outcome of MAKE30 with a statistically significant reduction in the balanced crystalloid group.8 However, the SPLIT trial in 2015 showed no difference in the primary outcome of AKI within 90 days.9 The SMART, SALT-ED, and PLUS trials showed statistically significant lower concentrations of chloride and higher pH levels in patients treated with balanced crystalloids compared to normal saline.7, 8, 10 The most recent trial, the PLUS trial, found no statistically significant difference in the primary outcome of death from any cause.10 The table below (Table 2) highlights pertinent studies comparing balanced crystalloids to saline. In the trials listed, rate and volume of fluid administered was chosen at the discretion of the treating physician. The 2022 New England Journal of Medicine meta-analysis estimates the effect of using balanced crystalloids versus normal saline ranges from 9% reduction to 1% relative increase in death, concluding there is a high probability that balanced crystalloids reduce mortality.11
In regards to fluid choices for initial resuscitation in sepsis, the change to recommend balanced salt solutions over normal saline is weak with a low quality of evidence. This change, in addition to the weakening of the recommendation for 30 mL/kg of fluids to be given, is aimed to improve the care of patients with sepsis.2 While more data are needed to strengthen fluid recommendations, current guidelines and clinical data can guide decision making in the setting of fluid resuscitation in sepsis.