A. Hugh Greene, FACHE, President and CEO, Baptist Health - 2013 Community Lea...
Winter 2012
1. Winter 2012 / Volume 55, No. 1
Northwest Pharmacy Convention
May 31st - June 3, 2012
Coeur d’Alene, Idaho
Pg. 6
2012 Winter Seminar
January 8 - 10, 2012
Westin Riverfront Resort and Spa, Avon, CO Pg. 32
Special Features
Membership Northwest Pharmacy New Requirement for
Highlights Convention CE Partcipants
See page 4-5 See page 6 See page 27
3. WSPA Board of Directors
President
Julie Akers
President-elect
Brian Beach
Immediate Past President
Ron Williams Winter 2012/Volume 55, No. 1
Secretary/Treasurer
Steve Singer
Features
board members
Beth Arnold mEMBERSHIP 4
Kurt Bowen (Student) Why you should renew your membership
Jill Carrier (Technician)
Northwest Pharmacy Convention 6
Shaelah Easterday (Student) Register Today!
Heather Ferguson
Christopher Foley (Student) Legislative and Regulatory Affairs Council News 11
Melissa Hansen Legislative Update
Andrew Heinz (Student)
Kirk Heinz Legislative Day 12
Anne Henriksen
Paul M. Iseminger (Technician)
Greg Matsuura School News 13
Cindy Wilson Get the Latest WSU/UW Information
Roger Woolf
departments and specials
managing editor
Kathleen Goodner Continuing Education 21
Health Information Exchange 17
Publisher
The Washington Pharmacy is owned and published Rx and the Law 31
by the Washington State Pharmacy Association Upcoming Events 32
to provide information, news and trends in the
profession of pharmacy. Opinions expressed by the
contributors, whether signed or otherwise, do not
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are they responsible for them. Subscription rate is
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class postage.) Bi-Mart 30
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published quarterly for $24 per year domestic / $59 Good Neighbor Pharmacy 18
foreign including first class postage by Washington McKesson 16
State Pharmacy Association at 411 Williams Ave. S, Pace Alliance 19 & 20
Renton, WA 98057. PERIODICALS Postage paid at
Renton, WA and at additional mailing offices.
Pharmacists Mutual 29
RxRelief 30
POSTMASTER
Please send address changes to:
Washington State Pharmacy Association
411 Williams Avenue S Staff
Renton, WA 98057
Jenny Arnold, Director of Pharmacy Practice Development
MISSION STATement
The Washington State Pharmacy Association exists Danyal Henderson, Administrative Coordinator
to advocate on behalf of its members to ensure
pharmacy professionals are recognized, engaged Dedi Hitchens, Director of Government Affairs
and valued as essential to the health care team.
Kathleen Goodner, PR & Communications Manager
Visit wspa’s website at
Maria Lieggi, Membership & Education Administrator
www.wsparx.org
Jeff Rochon, Chief Executive Officer
4. Why you Should renew today!
IT’S YOUR FUTURE STRENGTHEN YOUR SKILLS
Health care is in a dynamic state of Opportunities abound for you as a WSPA
change. Decisions impacting pharmacy member. Participate in quality conferences,
are made all the time. As the adage goes, seminars, and workshops that will contribute
“If you are not at the table, you are on the to your continuing education and professional
menu.” The WSPA is your invite to the table. development. Attending WSPA events helps
Since health care reform is implemented to build your network and meet key players
at a state level, it is crucial that you are in pharmacy, while learning about new and
engaged and involved in those decisions. upcoming therapies, products, services, issues
and developments.
The WSPA is your voice to advocate for
advancing the profession and protecting Whether you are looking for high-quality, timely
your livelihood. CE that is relevant to your practice, or you want
to learn about best practices from experts in
AMPLIFYING YOUR VOICE your specialty, the WSPA has something for you.
WSPA advocates for the profession on MAKE CONNECTIONS
numerous levels to: strengthen and
expand our role in patient care; protect WSPA provides opportunities to meet and
access to pharmacy-provided services network with people in the pharmacy
and products; and reinforce the value of profession. When you join the WSPA, you have
pharmacies in ensuring patient safety and the opportunity to join one or more practice
member only information quality health outcomes. academies to connect with professionals from
similar practice settings that allows you to:
WSPA works within multidisciplinary • Solve problems
WSPA is the source for news and information about
committees, patient advocacy groups, • Share ideas
the pharmacy profession and the members it serves,
regulatory agencies, public health • Move your practice forward
and routinely provides members with relevant,
jurisdictions, other professional
valuable and timely information on the latest safety,
associations, health insurance payers and WSPA academies include:
regulatory and legislative news. Members receive:
employers. • Ambulatory/Community Practice
• Health Systems
• Access to “Members Only” online Resource
On a legislative level, WSPA works within • Independent Pharmacy
Centers for Audit Avoidance & Protection,
LRAC to ensure lawmakers understand the • Long Term Care
Handling of Hazardous Drugs, Billing for Patient
pharmacy profession. • Students
Care Services, Compliance and Regulations,
• Technicians
Medication Safety, Medicaid, Medicare, Labor and
Industries Resource Centers, Pharmacy Security,
Whatever your practice setting or background,
Non-English Communication Tools and much
WSPA offers plenty of resources to build a
more
powerful network of professionals in pharmacy
• Timely and valuable information via email alerts
who can serve as mentors and support.
and Washington Pharmacy, the association’s
quarterly magazine
The Washington State Pharmacy Association
• WSPA Career Center and Salary Survey
offers a comprehensive suite of benefits and
• Quality On Demand Online CE
services that give members of all practice
• If you are Washington State Legislative and
settings and career levels the tools they need
Regulatory Affairs Council (LRAC) member,
to succeed. Take a look at all WSPA has to offer
you will also receive LRAC updates. It’s easy to
and join your colleagues who are dedicated to
become a member! Just mark the LRAC box on
pharmacy. Become a member today!
the membership form
Together we are stronger!
Washington State Pharmacy Association
411 Williams Avenue South
Follow the WSPA on Facebook, Twitter, and LinkedIn!
Renton, WA 98057
425-228-7171
Fax 425-277-3897
4 Washington Pharmacy www.wsparx.org
11. Legislative Day 2012
T
he 2012 Pharmacy Legislative Day was
another huge success! Pharmacy’s pres-
ence in Olympia was evident as more than
100 students in white coats from UW and WSU
joined faculty members, alumni and pharmacy
practitioners to advocate for the value of the
pharmacy profession in impacting patient care.
In a direct effort to advocate for the pharmacy
profession, Jeff Rochon, Chief Executive Officer
of the Washington State Pharmacy Association,
Dedi Hitchens, Director of Government Affairs
for Washington State Legislative and Regulatory
Affairs Council and Lis Houchen, Regional Direc-
tor of State Government Affairs for the National
Association of Chain Drug Stores set the tone for
several high profile speakers including: Lieuten-
ant Gov Brad Owens; Senator Linda Evans-Par-
lette, the only pharmacist legislator in Wash-
ington; Jason McGill the Governor’s HealthCare
Advisor; David Hanig, Senior Health Care Advisor
for the Senate Democratic Caucus; Marty Brown,
the Director of the Office of Financial Manage-
ment; Senator Karen Kaiser, Chair of the Senate
Health and Wellness Committee and Courtney
Acitelli, Program Director for UW Impact.
The day included 56 meetings with Senators and
Representatives from across the state. Pharma-
cists and pharmacy students addressed key bills
such as Including Pharmacists in the Legend
Drug Act, Pharmacist Provided Medication
Review for Medicaid Managed Care Enrollees,
PBM Transparency, e-Prescribing of CII Medica-
tions and Increasing Penalties for Crimes Against
Pharmacies.
An event of this magnitude would not be pos-
sible without dedicated volunteers and gener-
ous sponsors. A special thank you to Kurt Bowen,
Shaelah Easterday, Chris Foley, Nathan Deney
and Andrew Heinz for coordinating the phar-
macy student leaders. Thank you to Safeway for
providing water and a big thank you to Bartell
Drugs, Fred Meyer Pharmacy, and Spokane
Pharmacy Association for providing the funding
needed for the day’s event.
Washington Pharmacy 11
12. LRAC News
By Dedi Hitchens, Director of Government Affairs
T
he 2012 Washington State legislative session began in Janu- Drug Act, SHB 2512 and SSB 6197, successfully moved past the sched-
ary with a daunting $1.5 billion budget deficit despite a special uled legislative cut off dates and were voted on in both the House
session prior to regular session. State lawmakers are required by and Senate. Both chambers voted and received unanimous support
state constitution to fill the budget hole for the 2011-2013 supple- votes. During the second phase of the political process, legislators
mental budget biennium. Regular Session came and went and the decided to move just one bill, SHB 2512. This bill was next in line for
budget was not resolved so a second 30 day special session was called the Senate vote when three Democrats sided with the Republicans to
in March. Here’s a summary of the flurry of activity and efforts by the successfully moved their proposed operating supplemental budget
Washington State Pharmacy Legislative and Regulatory Affairs Council to the floor for consideration. This bold move occurred two hours
(LRAC). prior to the 5 pm cut off and killed the bill and several others that
needed to be voted on.
The first few weeks of the legislative session was filled with policy
committee hearings on policy bills. LRAC began the session with an Senate Budget Fireworks
aggressive agenda including pushing for bills to create Pharmacy Ben- In an unprecedented move, the Senate Republicans took the reins of
efit Manager (PBM) transparency requirements, include pharmacists the Democratic controlled Senate. The three Democrats sided with
in the Legend Drug Act, and increasing penalties for crimes against the Republicans procedural move to circumvent the public hearing
pharmacies. LRAC was successful in getting all of our bills heard in process and successfully moved their proposed operating supple-
their respective committees. mental budget to the floor for consideration. The Senate is narrowly
controlled by the Democrats with a small margin 27 Democrats to
PBM Transparency 22 Republicans. Growing frustration with the Senate Democrats
In the first year for this legislation in Washington State, LRAC success- proposed supplemental operation budget prompted the Republicans
fully got this issue recognized by legislators. The PBM transparency to effectively gain control with the help of three Democrats, who
bill had public hearings in both the House Healthcare and Wellness also have also expressed frustration over the Democrats budget. This
Committee and the Senate Health and Long Term Care Committee. bold move occurred two hours prior to the 5 pm cut off and killed a
Thank you to the LRAC members who testified in support of the PBM number of bills that needed to be voted on.
Transparency Bill. LRAC members representing independent and
chain pharmacy educated lawmakers about their experiences with The Senate Republicans, with a narrow vote of 25-24 successfully
PBM’s. The hearing raised a number of questions and interest among passed their Operating Budget. This move shifted momentum in the
lawmakers to look further into this issue. LRAC faced tremendous op- legislature, resulting in a Special Session. The Senate Republicans
position from the powerful PBM lobby, and Insurance lobby. The PBM disagree with the Democrats’ proposal to delay payments to public
lobby recruited PhRMA and a few employer groups to create confu- schools by one day – which is equivalent to $350 million. This delay
sion for legislators. However, LRAC was successful in getting the issue in payment would have moved the budget deficit to the next budget
heard in public hearings and now have some legislators interested cycle. The Republican budget cuts the Basic Health Plan and elimi-
in investigating PBM practices. This is a new issue to most lawmakers nates the Disability Lifeline program. Both programs were preserved
and one that can get confusing. This is going to be a long term effort under the Democrats proposal. Cuts to K-12 and Higher Education are
and further work will be done educating lawmakers and executive also being proposed.
policy staffers exposing PBM practices. LRAC will be working with the
Chairs of the Senate and House Health Care committees organizing an House of Representatives’ Budget
interim work session on PBM’s. The Washington State House of Representatives is a different story
and is likely to give back some democratic leverage to the operating
Increasing Penalties for Crimes Against Pharmacies budget negotiation. The House of Representatives does not have
LRAC reintroduced a bill attempting to move the crime of robbing a such a narrow margin of Democrat control. The House Democrats are
pharmacy from a second degree offense to first degree offense. This in the clear majority with a margin of 56 Democrats to 42 Republi-
bill was met with concerns in the Senate over the costs of increas- cans. The Senate Republican’s budget is sure to run into road blocks
ing incarceration periods. An amendment which still increases the in the House. LRAC successfully removed non-mandatory prescription
penalties by making the crime of robbing a pharmacy a mandatory co-payments from the House’s proposed operating budget and we
12 month jail sentence was agreed upon. It also permits the court the fought off a professional license fee increase to fund the Prescription
option to impose a stricter sentence based on consideration of the Monitoring Program.
circumstances of the robbery. Unfortunately, the bill did get a fiscal
note attached to it and that was the death of the bill. Under normal While politics is a tricky world where victories are often not apparent,
legislative circumstances the fiscal note would not have been an issue, LRAC was very successful this year. Even though an unprecedented
however, lawmakers are hard pressed to move forward on any bills Senate upheaval killed the bills, issues were heard and supported
that have even a potential to fiscally impact the state. The good news, by legislators. LRAC’s voice is prominent and we have worked in col-
Washington State’s pharmacy robberies have decreased over the laboration with provider associations, patient advocacy groups and
years. However, LRAC still views this bill as important and will continue legislative leadership to recognize and support the role of pharmacy
to try and get this bill passed. on the health care team. There is more work to be done as this ses-
sion closes and LRAC is committed to work tirelessly throughout the
Including Pharmacists in the Legend Drug Act interim to advocate for the pharmacy profession.
There were two bills aimed at including pharmacists in the Legend
12 Washington Pharmacy
13. School News
Construction of new building underway School News:
Construction began in August 2011 on a new building in Spokane, “U.S. News & World Report” has ranked the UW School of Pharmacy’s
which the College will share with the physician education program PharmD program 10th in the nation among all pharmacy schools.
jointly administered by WSU and the University of Washington.
The 2011 Washington Legislature allocated one-half the construc- The 2012 School of Pharmacy Don B. Katterman Lecture topic will
tion funding for the building, and the College is anticipating the be 'Demonstrating Impact: Making the Case for Pharmacy Services.'
2012 Legislature will provide the second half. It is a panel discussion in which the panelists will offer examples of
how to improve health outcomes while also increasing revenue.
Sources of funding to furnish and equip the new building – includ- The panelists are Washington State Pharmacy Association Director
ing research laboratories, classrooms and space for faculty, staff of Pharmacy Practice Development Jenny Arnold, Walgreens Co.
and students -- are being sought. The College will move its Pullman District Pharmacy Supervisor Daiana Huyen, Katterman’s Sand Point
facilities to Spokane once the building is finished. Pharmacy Co-owner and Pharmacist Beverly Schaefer, and Virginia
Mason Medical Center Administrative Director of Pharmaceuti-
Pharmacy undergraduate summer research program receives cal Services Roger Woolf. The event is May 8th at 7 p.m. on the UW
funding campus. A reception will take place beforehand at 6 p.m. CE credits
are available. Visit www.pharmacy.washington.edu/katterman2012
Funding for an undergraduate summer research program in the for more information.
College of Pharmacy has been renewed by the American Society of
Pharmacology and Experimental Therapeutics. The Pharmaceutical Outcomes Research and Policy Program (PORPP)
ASPET awarded the College $27,000 – or $9,000 per year – for the has created its first ever endowed directorship — the Stergachis
next three years and has funded the program for nine of the last 10 Family Directorship. It is named after Andy Stergachis, professor of
years, according to Raymond M. Quock, pharmaceutical sciences epidemiology and global health and adjunct professor of pharmacy,
department chair. and his wife, JoAnn Stergachis, a sales executive with F5 Networks.
Andy Stergachis was the founding director of PORPP and former
The College must match the award with $5,000 per year, and the chair of the Department of Pharmacy.
money allows student researchers to be paid a stipend for their 10
weeks of full-time work on research with a faculty mentor who is PORPP is also launching an online certificate program in health eco-
an ASPET member. Additional College funds and various research nomics and outcomes research. Find out more at http://www.pce.
grants and fellowships are used to allow more students and faculty uw.edu/certificates/health-economics/web-autumn-2012/.
who are not ASPET members to also participate in the program.
Faculty News
WSU PharmD Class of 2015 Profile
• 84 students Dean and Professor of Medicinal Chemistry Thomas Baillie has
• 66 students have bachelor’s degrees received the 2012 Founders’ Award from the American Chemical
• Average age is 25.3 years Society Division of Chemical Toxicology. The award will be presented
• 57 females, 27 males at the ACS Fall National Meeting on August 19, 2012 in Philadelphia.
• 56 students from Washington state As the Founders’ Awardee, Baillie will organize an award symposium
• 10 students from California highlighting work in his area of research.
• Other states represented are: Idaho, Oregon, Hawaii, Arizona,
Texas, Utah, Colorado With the help of the UW Center for Commercialization, Professor of
Medicinal Chemistry Dave Goodlett and Dr. Patrick Langridge-Smith
of the University of Edinburgh have formed a company, Deurion
LLC, to further develop and make commercially available the Surface
Acoustic Wave Nebulization (SAWN) method of mass spectrometry.
The Goodlett Lab developed this technology in 2011. In December,
Deurion received a $150,000 National Science Foundation grant to
continue its work. This grant built on a UW C4C Gap Fund of $50,000
that Goodlett received last summer to construct a prototype SAWN
device.
Washington Pharmacy 13
14. School News
Assistant Professor of Pharmaceutics Nina Isoherranen has been elected Meeting. The project was also named one of the top 50 student-submit-
Secretary/Treasurer of the Drug Metabolism Division of the American ted abstracts for the meeting. She will receive a travel stipend from AGS
Society for Pharmacology and Experimental Therapeutics. to attend the meeting. In addition, this same project was accepted as
Associate Dean Nanci Murphy and pharmacy student Denise Ngo, ’14, a podium presentation at the 2012 Southern Pharmacy Administration
received a Project CHANCE award from the American Pharmacists As- Conference and the Western Pharmacoeconomic Conference.
sociation-Academy of Student Pharmacists (APhA-ASP). They accepted
the award from APhA-ASP and the Pharmacy Services Support Center
of the Health Resources and Services Administration in March in New
Orleans. This award will help fund an interprofessional student outreach
project at Community Health Care in Lakewood.
Hollywood Glamour
Pharmacy Student News:
The UW student chapter of the American Pharmacists Association
(APhA)-Academy of Student Pharmacists won the Chapter of the Year
Award in the AAA division at the APhA convention in New Orleans. The
group was honored for their community outreach to tribes, legislative
advocacy and international health programs, among other activities.
Elise Fields, ‘12, recently returned from an advanced pharmacy practice
experience rotation in Windhoek, Namibia, where the UW has a strong
institutional relationship with University of Namibia, the Ministry of
Health and Social Services’ Therapeutics Information and Pharmaco-
vigilance Centre, and Management Sciences for Health-Namibia. For
this experience, Fields received a UW Thomas Francis, Jr. Global Health
Fellowship Award.
Kathy Glem, ’13, Cate Lockhart, ’13, Tahlia Luedtke, ’14, and Anne Spen-
gler, ’13 won the UW Pharmacy and Therapeutics Competition.
Denise Ngo, '14, received a scholarship from the National Association
of Chain Drug Stores Foundation for her work supporting continuing 2012 UPPOW Auction
education programs that focus on patient-centered care in community
pharmacies.
Blaze Paracuelles, '14, received a UW Medical Center Martin Luther King
Jr. Community Service Award.
Friday, April 13, 2012
Grad Student News: 7:00-11:00 pm
PORPP student Carrie Bennette received a scholarship from the Ameri- University of Washington’s Kane Hall
can Society of Health Economists to attend the ASHE conference in
Minneapolis in June.
Walker-Ames Room
Veena Shankaran, a student in the Pharmaceutical Outcomes Research Tickets: $15
& Policy Program (PORPP), has received the PORPP Endowed Prize in
Health Economics and Policy. This award recognizes her research on the
risk factors for financial hardship in colon cancer patients. Please support professional development of student
pharmacists with your attendance or tax-deductible
Pharmaceutics graduate students Diana Shuster and Jenna Voellinger donation.
each received an Institute of Translational Health Sciences (ITHS)
TL1 Multidisciplinary Predoctoral Clinical Research Training award of
$21,600 for the upcoming academic year. The ITHS TL1 program spon- Contact: Kristine Kim (kkim44@gmail.com)
sors a year-long intensive clinical/translational research experience for
predoctoral students to conduct an original research project.
PORPP student Heidi Wirtz’s project entitled, "Anticholinergic Medica-
tion Use, Falls and Fracture in Postmenopausal Women: Results from the
Women's Health Initiative" was accepted for an oral podium presenta-
tion at the 2012 American Geriatrics Society (AGS) Annual Scientific
14 Washington Pharmacy Washington Pharmacy 14
15. Sid Nelson
UW Mourns One of Their Own
Contributed by UW School of Pharmacy Dean Thomas Baillie
Toxicology from the Society of Toxicology, to name a few.
Nor is it just about the deep love he had for this School of Pharmacy,
his colleagues and our students. Sid was a constant presence at
student events, alumni events and industry events over the years. He
was an enthusiastic supporter of the people around him — cheer-
ing loudly in the audience (along with his wife, Joan) at academic
and industry events when our pharmacy students received awards;
proudly supporting his Ph.D. students at scientific conferences around
the world; regularly nominating his colleagues for prominent scien-
tific honors; sending personal notes to alumni and former classmates
when he heard exciting updates about their lives; and giving gener-
ously to the School of Pharmacy in the form of scholarships and a fund
he and his wife created.
Indeed, there are just too many good things to say about Sid to encap-
sulate what he meant to all of us. I suppose, when it comes down to
it, what we will all miss about him most was his kind spirit. Sid Nelson
was a caring, genuine man who made a positive impression on every-
one who had the good fortune to know him. The School of Pharmacy
is not going to be the same without him. We will all remember his
off-color sense of humor, his giant collection of penguin paraphernalia
and his enduring authenticity.
Sid himself was an alumnus of the University of Washington School of
Pharmacy, graduating in 1968 with a B.S. in pharmacy. He went on to
receive a Ph.D. degree in medicinal chemistry from the University of
California, San Francisco. He joined the UW School of Pharmacy faculty
in 1977.
He was dean of our School from 1994 to 2008. Under his leadership,
the School converted from a B.S. degree to an entry-level Doctor of
Pharmacy degree program and added a nontraditional approach
that enabled existing pharmacists to obtain the Pharm.D. degree. He
also evolved the graduate programs and worked tirelessly to expand
"Students and colleagues of Sid Nelson will recall the large collection of pen- the School’s faculty. In 2008, he returned full time to his research and
guin paraphernalia in his office. Over the years, he amassed this collection — teaching activities in the School’s Department of Medicinal Chemis-
many of the items were gifts — after he made a stuffed penguin the unofficial try. In recent years, Sid held an NIH fellowship to conduct research in
mascot of his lab."
metabolomics/metabonomics at Imperial College London and he was
I
named a National University of Singapore distinguished professor.
t is with profound sadness that the UW School of Pharmacy an-
nounces that Professor of Medicinal Chemistry and Dean Emeritus On a personal note, I had known Sid for some 35 years, having first met
Sidney “Sid” Nelson passed away suddenly on Friday, December him at a scientific conference in Europe while he was a fellow at NIH
9th. He was 66 years old. and I was a young faculty member at the University of London. We be-
came good friends and kept in close contact over the years, eventually
It is hard to put into words the impact that Dr. Sid Nelson had on this working together as faculty colleagues in the Department of Medicinal
School, the University, the scientific community and everyone who Chemistry at the UW in the 1980s through 1990s. When I returned to
knew him. the School of Pharmacy in 2008 to take over as dean, I knew I had big
shoes to fill, but I also knew that he had left me a remarkable institu-
It’s not just about the awards and honors Sid received for his leader- tion that he had played a major role in building — with an exceptional
ship, his teaching and his prolific research — and there were many: community of faculty, staff, students and alumni.
Dean of the Year from the American Pharmacists Association – Acade-
my of Student Pharmacists, American Association of Colleges of Phar- His death is a major loss to our School, the University of Washington,
macy Volwiler Research Achievement Award, UW Gibaldi Excellence academic pharmacy nationally, and the global scientific community.
in Teaching Award, UW School of Pharmacy Distinguished Alumnus It was an honor to know him as an educator, mentor, colleague and
Award, John J. Abel Award from the American Society of Pharmacol- friend.
ogy and Experimental Therapeutics, and the Frank R. Blood Award in
Washington Pharmacy 15
17. Health Information Exchange (HIE)
Q&A on HIE
• Business based – satisfying a key business or grant requirement
What are your key interests in Health
The key question Sue Merk and Susan Boyer will be exploring is what
Information Exchange (HIE)? are the highest priority communities of interest for Pharmacy with the
HIE? Some possibilities might be:
T
he collaboration between the Washington State Pharmacy
Association (WSPA) and OneHealthPort is entering a new • Using a common referral management form to share information
phase. Over the past year Sue Merk, WSPA member, Senior with physicians about adverse drug reactions or patient
Vice President at OneHealthPort and the person leading the compliance.
statewide HIE effort has spoken in a number of WSPA venues. She
has described the early stages of the HIE and • Connecting groups of local pharmacists
shared some initial thoughts about how the with their local physician trading partners
HIE can benefit Pharmacists. Sue’s experience to do eprescribing without those expensive
and the tremendous feedback she received transaction fees
have convinced OneHealthPort of the need to
explore the HIE issue in greater depth with the Learning more about these ideas and most
Pharmacy Community. importantly filling in that last blank with new
ideas is what Susan Boyer’s engagement for
OneHealthPort and WSPA discussed a variety OneHealthPort is all about. OneHealthPort
of approaches to gather information with an wants to understand:
eye toward tailoring an HIE offering specifically
to Pharmacy. Ultimately, both groups decided • How current arrangements with
what was needed was more than a survey, what was needed was a SureScripts and others are working or not?
conversation. To facilitate this conversation, OneHealthPort was very
pleased to discover just the right person at just the right time. At • What Pharmacy information exchange needs are currently being
the end of March, Susan Boyer will complete her work as Executive met, where?
Director of the Washington State Board of Pharmacy and become an
independent consultant. OneHealthPort has secured Susan’s services • What urgent information exchange needs are not being
to lead a conversation with the Pharmacy Community about the HIE addressed with current solutions?
opportunity.
The HIE is a flexible, low-cost exchange service. This is your chance to
As OneHealthPort has worked to deploy the HIE in Washington create a community of interest around your exchange needs, with your
state, it has gained a number of insights. One key insight has been key trading partners and solve your pressing problems.
the emergence of “Communities of Interest.” By definition HIE is an
“exchange,” it is not a solitary activity within a single enterprise, it is Susan will begin her work on OneHealhPort’s behalf in mid-April. At
at least two and often multiple organizations that come together that time she’ll be reaching out to the Pharmacy Community. In the
around a specific information need. These organizations share a interim you can check out the latest news about the HIE at:
common interest in electronic health information exchange and so
form a “community.” The interests can be: http://www.onehealthport.com/HIE/index.php
• Geographical – health care organizations located near each OneHealthPort and WSPA are both looking forward to the upcoming
other that want to form a local network conversation beginning in April.
• Transactional – different enterprises that want to exchange a
specific data set
Washington Pharmacy 17
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20 Washington Pharmacy
21. continuing education for pharmacists
Volume XXX, No. 2
Restless Legs Syndrome and Management
Thomas A. Gossel, R.Ph., Ph.D., Professor Emeritus, Ohio Northern University, Ada, Ohio and
J. Richard Wuest, R.Ph., PharmD, Professor Emeritus, University of Cincinnati, Cincinnati, Ohio
Dr. Thomas A. Gossel and Dr. J. Richard to tolerate sedentary activities can
Wuest have no relevant financial relation- lead to a compromised ability to
ships to disclose.
enjoy life, and serious problems
maintaining relationships.
RLS hardly receives the atten-
Goal. The goal of this lesson is tion it deserves. It has attracted lit-
to review restless legs syndrome, tle attention in medical textbooks
with emphasis on presenting key until recently. A study conducted
points of information to pass along jointly in the United States and
to patients.
Gossel Wuest Europe suggests that the condi-
tion is not only under-reported,
Objectives. At the completion of the United States may experience but also greatly under-diagnosed
this activity, the participant will be RLS symptoms, although the exact and under-treated. A 1996 report
able to: prevalence may be much higher described the outcome of a group
1. demonstrate knowledge of because it is generally held that of patients who delayed seeking
restless legs syndrome including its many patients fail to discuss their medical help for many years, but
causes and triggers, epidemiology symptoms with healthcare provid- even after they did receive help, ac-
and prevalence, pathogenesis, and ers. Patients may believe their curate diagnosis frequently took a
clinical impressions; condition is too insignificant with decade or more. The Restless Legs
2. explain the mechanism of which to bother their physician, or Syndrome Foundation has taken
action and major adverse events they may not recognize that RLS account of these observations and
associated with the drugs used in can be symptomatic of more serious often reminds its constituency that
treating restless legs syndrome; pathology that requires physician RLS is “the most common disorder
3. select nonpharmacologic intervention. A sensorimotor (both you have never heard of!”
measures that are reported to sensory and motor) neurologic This lesson describes RLS,
modify symptoms of restless legs movement disorder, RLS causes including its clinical features and
syndrome; and patients to experience an almost medical management. It stresses
4. demonstrate an understand- irresistible urge to move their legs. information that will be useful not
ing of information relative to Usually worse during periods of only to pharmacists, but also to
restless legs syndrome to convey to inactivity or rest, walking or other patients who experience the condi-
patients and their caregivers. physical activity involving the legs tion.
can usually alleviate the sensa-
Background tions. Often associated with a sleep Epidemiology and
Restless legs syndrome (RLS), complaint, the inability to rest Prevalence
also known as Ekbon’s syndrome, can have a negative impact on the RLS can affect persons of any race
was named after Swedish neurolo- patient’s quality of life due to agita- or ethnic group, but it is more com-
gist/physician Karl Ekbon. In the tion, discomfort, frequent wak- mon in persons of Northern Euro-
mid-1940s, Ekbon described the ing, chronic sleep deprivation and pean descent. African Americans
condition as a common and dis- stress. These conditions, in turn, are affected significantly less often
tressing condition, but one that is can negatively affect job perfor- than Caucasians. Its prevalence is
readily treatable. Two to 15 per- mance, social activities, and family distinctly lower in Asian popula-
cent of the general population of life. Disturbed sleep and inability tions, ranging from 0.1 percent in
Washington Pharmacy 21
22. Etiology and when attempting to control symp-
Table 1 Pathophysiology toms.
Drugs reported to Although RLS is a disorder of the Secondary Causes. A number
exacerbate RLS central nervous system, it is not a of secondary causes of RLS have
psychophysiologic pathology; how- been identified. For example, symp-
• Alcohol toms of RLS may be associated
• Analgesics (NSAIDs, non-opioid)
ever, it may contribute to or be ex-
acerbated by such conditions. RLS with iron deficiency. A patient’s
• Anesthetics (bupivacaine,
can generally be categorized into iron stores may be deficient with-
mepivacaine)
• Anticonvulsants (methsuximide, primary (idiopathic) and secondary out causing anemia. Studies have
phenytoin, topiramate, zonisamide) forms. Primary RLS is not related shown that decreased iron stores
• Antidepressants (mirtazapine, to other identifiable abnormalities; (i.e., ferritin levels below 50 µg/L)
SSRIs, trazodone, tricyclics, secondary RLS is associated with can exacerbate RLS symptoms.
venlafaxine) an underlying pathology. When Iron is an essential cofactor for
• Antihistamines (older) tyrosine hydroxylase, the rate-lim-
no specific cause can be identified
• Antipsychotics (clozapine, iting enzyme for dopamine synthe-
olanzapine, quetiapine,
for initiating RLS symptoms, it is
considered a primary condition. sis. Animal studies demonstrate
risperidone)
It is thought that RLS may be that iron deficiency is associated
• Beta-adrenergic blockers (pindolol)
• Caffeine due to dysfunction of dopamine- with hypofunction of dopamine D2
• Donepezil producing cells in the nigrostriatal receptors that is corrected by iron
• Interferon-alfa/ pegylated areas of the brain. Pharmacologic replacement. The fact that the
interferon-alfa studies have shown a dramatic extent of iron deficiency correlates
• Levothyroxine improvement in RLS symptoms well with symptoms and that iron
• Lithium is an effective therapy, at least
with administration of levodopa,
• Methadone (withdrawal) in iron-deficient patients, provide
• Metoclopramide
the precursor of dopamine, or with
dopaminergic agonists that act on strong support for the role of iron
• Nicotine
dopamine receptors in the brain. deficiency in the pathogenesis of
• Sodium oxybate
Conversely, dopamine antagonists some patients with RLS. Physi-
will worsen symptoms in patients cians often order serum ferritin
with RLS. Advanced brain imaging levels in patients with newly diag-
Singapore to 4.6 percent in elderly has revealed decreased dopamine nosed RLS or RLS patients with a
Japanese. Epidemiological studies D2 receptor binding in the striatum recent exacerbation of symptoms.
in the general population of the of patients with RLS. Hypoactive Once iron levels are corrected (dis-
United States and Europe show dopaminergic neurotransmission cussed subsequently), symptoms
widely different prevalence rates, in RLS has recently been demon- are reduced.
probably related to the variety of strated and study results suggest RLS has been reported in per-
experimental design. Prevalence that both striatal and extrastriatal sons with spinal cord and periph-
of RLS among patients in primary brain regions are involved. eral nerve lesions, and in patients
care settings has also been esti- The high incidence (40 to 60 with vertebral disc disease. The
mated. Results from a large survey percent) of familial cases of RLS exact pathological mechanism
of primary care centers in Europe strongly suggests a genetic origin remains unknown.
and the United States reported for primary RLS, especially if the RLS occurs in up to one-half of
that overall, 11.1 percent of pa- condition onsets at an early age. patients with end-stage renal fail-
tients experienced any degree of Family and twin studies have ure. Symptoms may be especially
RLS symptoms, while 9.6 percent proposed both autosomal-dominant bothersome during dialysis when
reported symptoms at least once as well as recessive modes of in- the patient is in a forced resting
weekly. heritance. Genetic studies suggest position. Improvement in RLS
RLS has a variable age of onset several chromosomal loci associ- symptoms has been shown after
with prevalence increasing with ated with RLS. At present, five renal transplantation.
advancing age. It can also occur in loci have been mapped for RLS in One in five women experi-
children. Studies confirm that in single families, and three suscep- ence symptoms during pregnancy,
patients with severe RLS, one- tibility loci have been identified in especially in their last trimester.
third to two-fifths experienced their a genome-wide association study. Some women, in fact, report RLS
first symptoms before age 20 years, Secondary causes of RLS are more for the first time during pregnancy.
although a precise diagnosis of RLS common in persons who develop Symptoms can be severe, but usu-
was made much later. Women are symptoms for the first time in later ally subside within four weeks
twice as likely as men to develop life; secondary RLS occurs in over postpartum.
RLS. 70 percent of persons with onset at RLS symptoms may be wors-
age 65 years or more. It is impor- ened or unmasked by a variety of
tant to rule out secondary RLS medications (Table 1). As a group,
22 Washington Pharmacy
23. lower legs (calves); however the
Table 2 aggravating sensations may also
Table 3
Terms patients may use occur any place in the legs or feet.
Criteria for diagnosis
when describing They may also occur in the arms
of RLS
RLS symptoms or elsewhere. The feelings seem Diagnostic criteria*
Aching Flowing water
to originate from deep within the •Compelling urge to move the limbs,
Burning Numb limbs, rather than from the joints, usually associated with paresthesias/
Buzzing Painful or on the surface. The sensations dysesthesias
Cramping Pulling are usually bilateral, but may oc- •Motor restlessness as noted in
Crawling Restless cur in one leg, move from one leg activities such as floor pacing and
Creeping Searing to the other, or affect one leg more rubbing the legs
Drawing Tense than the other. The pain is more of •Symptoms present or worse during
Electric current-like Tingling rest, with temporary relief by activi-
an ache rather than sharp, jab-
Gnawing Tugging ties such as walking or stretching, at
bing pain. Symptoms are generally least as long as the activity continues
Indescribable Uncomfortable
Itching
worse in the evening and night, •Symptoms worse in evening and at
Feeling of worms or bugs crawling and less severe in the morning. night than during the day, or occur
under my skin Symptoms appear with rest, sitting only in the evening or night
or lying down. The more comfort-
able the patient is, the more likely Supportive clinical features±
antidepressants are the drugs most it is that RLS symptoms will occur. •Sleep disturbance and daytime
commonly implicated in secondary The reverse is also true – the less fatigue
RLS with almost all classes report- comfortable the patient is, the less •Normal neurological examination in
ed to worsen symptoms. Persons primary RLS
likely it is that symptoms will on- •Involuntary, repetitive, periodic,
with RLS who take one or more set. As a result, some patients may
of the listed drugs are advised to jerking limb movements during sleep
prefer to sleep on a hard surface or while awake
discuss with their physician the including the floor rather than in •Positive family history of RLS
possibility of changing medications a comfortable bed. The condition •Positive response to dopaminergic
to improve symptoms. should be distinguished from sleep- therapy
related disorders of the legs.
Clinical Assessment Periodic Limb Movements Associated features§
A diagnosis of RLS is based pri- in Sleep. The presence of repeti- •Natural clinical course: Onset age
marily on a careful patient history is variable, in patients with earlier
tive and highly stereotypic periodic onset (<50 years) the symptoms are
and detailed physical and neuro- limb movements in sleep (PLMS)
logical examination. There is no insidious, while patients with later
supports, but does not confirm, a onset have a more aggressive course.
laboratory test that can affirm the diagnosis of RLS. PLMS is also RLS is usually a chronic disease with
presence of RLS. The patient’s known as periodic limb move- a progressive clinical course; in the
physical examination is often ments and periodic limb movement mildest forms of RLS, the clinical
normal, except for those who have disorder, and was formerly referred course can be static or intermittent.
symptomatology suggestive of a to as myoclonus. PLMS is noted as •Sleep disturbances: disturbed sleep
secondary form of RLS or a comor- repetitive movements, typically in is usually associated with RLS.
bid condition. •Medical evaluation/Physical exami-
the lower limbs, that occur every nation: physical and neurological ex-
Symptoms may be described by 20 to 40 seconds. Symptoms can
patients as ranging from mild to amination is generally normal (except
also occur in the arms. Hundreds for secondary RLS). Medical evalua-
intolerable. Due to the subjective of these involuntary, rhythmic tion should be addressed to identify
nature of the disorder, however, muscular jerks in the lower limbs possible causes for secondary RLS.
patients often experience difficulty may occur, sometimes throughout
in describing their symptoms. the night. Affected persons are
Oftentimes their sensation defies often not aware they are experienc-
*Minimal criteria for positive diagnosis
description (Table 2). Confirmation of RLS
ing the movements. In a person ±Supportive clinical features common in
of RLS is not easy. A population with severe RLS, these involuntary RLS but not required for diagnosis
study showed that a large number kicking movements may also occur §These features may provide additional
of patients do not seek medical aid while awake. PLMS is common in
information about the patient’s diagnosis
because of their motor condition, older adults, even those without
but rather because of the conse- RLS, and doesn’t always disrupt Essential Criteria that Con-
quences of their disorder such as sleep. Eighty percent of persons firm RLS. The International Rest-
insomnia or decreased quality of with RLS also experience PLMS, less Legs Syndrome Study Group
life. which correlates with RLS sever- in collaboration with the National
Most patients with RLS ex- ity, but less than half of those with Institutes of Health has estab-
perience the feelings in their PLMS also have RLS. lished criteria for diagnosis of RLS
Washington Pharmacy 23
24. (Table 3). Four essential criteria such as deep vein thrombosis can and indeed, there are no FDA-
must be present to establish a posi- be confused with RLS. approved drugs for use in children
tive diagnosis. A mnemonic to help with RLS. Case histories and
remember these points is URGE: RLS in Children anecdotal reports suggest it is best
Urge to move, Rest induced, Gets Although RLS is generally dis- to begin with good sleep hygiene
better with activity, Evening and cussed as a disease of adults, over measures, cognitive behavioral
night accentuation. In the absence the past 20 years there has been therapy and caffeine restriction
of the core clinical features of RLS, increasing recognition that it also (including restriction of caffeinated
a positive diagnosis of RLS cannot occurs in children. Adults with soft drinks). If these measures are
be made, and other causes of PLMS the diagnosis often retrospectively ineffective, screening for anemia
or isolated periodic limb movement recall having had symptoms during and checking the patient’s serum
disorder must be considered. The their childhood. Case series have ferritin level makes sense. For
relation between PLMS and RLS described children as young as children, elemental iron in doses of
is unclear, but treatments used for 18 months of age with features of 3 mg/kg/day given for three months
RLS may also be effective in PLMS RLS. was shown to improve PLMS and
as well. The presence of supportive Diagnosing RLS in children is clinical symptoms, but more data
and associated clinical features as particularly difficult because clini- are needed to determine effective-
shown in Table 3 is not necessary cians rely heavily on the patient’s ness in pediatric RLS. Dopaminer-
for a positive diagnosis, but they description of symptoms. Even for gic drugs used “off-label” in chil-
are definitely helpful to the differ- adults with RLS, an accurate de- dren have been shown to improve
ential diagnosis. scription of its subjective symptoms RLS symptoms. In cases of associ-
Differential Diagnosis. RLS may be difficult. Children may ated ADHD, dopaminergics may
should be differentiated from other describe RLS symptoms differently benefit ADHD symptoms as well.
conditions including: than adults, using terms such as
•Nocturnal Leg Cramps. These oowies, ouchies, tickle, spiders, Treatment in Adults
typically include painful, palpable, twitchy, jerky, boo-boos, want to There is no cure for primary RLS.
involuntary muscle contractions, run, and a lot of energy in my legs. Both nonpharmacologic measures
often focal, with a sudden onset. Or, children may have at least two and pharmacotherapy, however,
Nocturnal leg cramps are usually of the following: sleep disturbance, are helpful in relieving symptoms
unilateral. a biological parent or sibling with in many patients. It is important
•Akathisia. This is a closely re- RLS, or polysomnographic-docu- to note that both severity and
lated disorder, described as a condi- mented PLMS. Determining RLS frequency of RLS are variable;
tion of motor restlessness, ranging in children can be aided using the therefore, nonpharmacologic thera-
from a sense of inner disquiet, to same four criteria as for adults (see pies alone may be appropriate for
inability to sit or lie quietly or to Table 3). milder forms of RLS and indeed,
sleep, with no sensory complaints. According to a recent survey these measures should be consid-
The restlessness is generalized and of more than 10,000 families in ered first in all but the most severe
internal rather than localized to the United States and the United cases. It is also important to note
the limbs and associated with par- Kingdom, RLS affects about 2 that many pharmacologic agents
esthesias. Akathisia often does not percent of children. A pediatric are used in an “off-label” basis.
correlate with rest or time of day, RLS prevalence of 5.9 percent was Successful treatment for secondary
and often results as a side effect of noted at one pediatric sleep disor- RLS requires treating the underly-
medication such as neuroleptics or ders clinic. Another study found ing cause. Goals of treatment are
other dopamine blocking agents. a prevalence of 1.3 percent in 12 to prevent or relieve symptoms,
•Peripheral Neuropathy. This pediatric practices, and another re- increase the amount and improve
can cause leg symptoms that are ported its occurrence in 6.1 percent the quality of sleep, and treat or
different from RLS. Symptoms are of Canadian children ages 11 to 13 correct any underlying condition
usually neither associated with years. The U.S./U.K. study found a that may trigger or worsen RLS.
motor restlessness nor lessened strong genetic component to RLS. Lifestyle and Behavioral
by movement. The condition is not More than 70 percent of children Changes. For those with mild-to-
worse during the evening or night- with RLS had at least one parent moderate symptoms, prevention
time. Sensory complaints include with the condition. There is also is key to their control. In gen-
numbness, tingling or pain. Small evidence suggesting that children eral, simple lifestyle changes that
fiber sensory neuropathies such as with attention deficit hyperactiv- promote good health can play an
those seen in diabetes mellitus may ity disorder (ADHD) and a family important role in alleviating symp-
be confused with RLS. Patients history of RLS are at risk for more toms of RLS. The measures listed
with neuropathies may have both severe ADHD. in Table 4 may help reduce the
neuropathic and RLS symptoms. Most children with RLS do not discomfort and excessive leg move-
•Vascular Disease. Conditions require pharmacologic treatment ments. The websites listed in Table
24 Washington Pharmacy
25. patients. Treatment must there-
Table 4 fore be individualized. Selection of
Table 5
Nonpharmacologic pharmacologic agents is influenced
Support groups for RLS
management of RLS by a number of factors, including: •Restless Legs Syndrome Foundation
•Patient Age. Benzodiazepines, www.rls.org
•Identify any underlying disorders
and treat, if feasible for example, may cause cognitive
•Eliminate precipitants of RLS impairment in elderly patients. •Worldwide Education and Aware-
-Drugs (see Table 1) •Symptom Severity. Patients ness for Movement Disorders
-Common stimulants and depres- with mild symptoms may elect to (WE MOVE)
sants: caffeine, alcohol, nicotine forgo using medications due to cost, www.wemove.org
•Practice good sleep hygiene adverse effects or other reasons.
-Establish regular sleep and wake •National Sleep Foundation
Others may benefit from a dop-
times www.sleepfoundation.org
aminergic agent or a dopamine
-Restrict bed to sleep and intima-
agonist. Severe symptoms may •National Institute of Neurological
cy; remove TV, stereo
-Avoid perturbing activities im- require a strong opioid. Disorders and Stroke (NINDS)
mediately before sleep •Symptom Frequency. Persons www.ninds.nih.gov/disorders/
-Avoid bright lights in late evening with infrequent symptoms may restless_legs/restless_legs.htm
or night benefit greatly from a single dose of
-Have a light snack before bedtime medication given on an as-needed •National Heart, Lung and Blood
•Apply simple behavioral basis, such as an opioid or levodo- Institute (NHLBI)
interventions www.nhlbi.nih.gov/health/dci/
pa.
-Brief walk before bedtime Diseases/rls/rls.htm
•Pregnancy. Neither safety
-Hot bath or cold shower
nor efficacy of medications for RLS
-Massage limbs
-Practice meditation and/or yoga has been assessed in clinical trials a while, patients start to awaken
-Avoid heavy meals within 3 hours involving pregnant women. early in the morning with recur-
of bedtime •Renal Failure. Most pharma- rence of their RLS. Sustained-re-
-Avoid excessive napping during cologic agents are generally safe in lease formulations can delay onset
daytime patients with renal failure, al- of rebound until later in the morn-
•Moderate exercise: neither inactivi- though dose frequency and quanti- ing, although the long-term efficacy
ty nor unusual and excessive exercise ty may be modified if the drugs are of this approach remains unknown.
•Weight management: healthy diet excreted via the kidney. Moreover, Augmentation is more serious.
and adequate activity
for dialysis patients, some medica- It may shorten symptom-free
•Information and support: use web-
sites and patient support groups (see tions are dialyzable (e.g., gabapen- periods at rest. Also, symptoms
Table 5) tin) while others are not. develop earlier in the day (morn-
Dopaminergic Agents. ing or afternoon instead of evening
Discovery that levodopa was ef- or night) and may become more
5 provide valuable information that fective in RLS revolutionized its severe; and symptoms may develop
can be passed along to patients. management. Every dopaminergic in parts of the body that were not
Pharmacologic. Although agent tested has been shown to be previously involved. Augmenta-
nonpharmacologic strategies may effective against RLS and PLMS. tion occurs in up to 80 percent of
work for some patients with milder Levodopa/carbidopa (Sinemet®, and patients treated with levodopa as
symptoms, most individuals with others) provides near-immediate early as four weeks into treatment.
mild-to-moderate symptoms will relief from RLS. The response is so Approximately one-third have
require medication to help make characteristic that a brief course sufficiently severe symptoms that
symptoms tolerable. Medical of therapy may be considered in warrant a change in therapy. The
management of RLS is a rap- patients whose diagnosis of RLS is precise mechanisms contributing
idly developing field. Large-scale in doubt. Levodopa is also effec- to augmentation are unknown. The
multicenter trials in RLS became tive in hemodialysis patients with need for higher doses of levodopa
common only since the beginning of RLS. In general, the drug is very and development of more severe
the 21st century. To date, only three well tolerated. Levodopa-induced RLS may predict development
drugs have earned FDA approval dyskinesias have not been reported of this complication. Levodopa
for RLS: ropinirole (Requip®) in in RLS patients. is, therefore, no longer the treat-
May 2005, pramipexole (Mirapex®) Two troublesome and common ment of choice for RLS, although
in November 2006 and gabapentin problems develop with prolonged it remains a therapy of choice for
enacarbil (Horizant™) in April use of levodopa, which limits the persons with only intermittently
2011. Since symptom severity var- value of this otherwise almost ideal severe symptoms.
ies greatly between patients, no agent for RLS: rebound and aug- Dopamine Receptor Ago-
single medication or combination of mentation. Rebound is an outcome nists. These are now regarded as
drugs will work predictably for all of the drug’s short half-life; after the first-line treatment for RLS.
Washington Pharmacy 25
