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What Pharmacists Need to know about Diabetes

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As per the Centers for Disease Control and Prevention (CDC), 34.2 million people, or 1 in every 10, in the United States have diabetes. Diabetes is 7th on the list of leading causes of death while the total estimated medical costs and costs associated with lost work and wages equates to an estimated $327 billion.

Diabetes, otherwise known as increased sugar levels (hyperglycemia) may be a result of decreased insulin secretion, decreased insulin sensitivity, or both. It can present itself in one of two forms of the following:

  • Type 1
    • Autoimmune destruction of beta cells
    • Loss of insulin production
    • Must use insulin injections
  • Type 2
    • Insulin resistance
    • Decreased insulin production over time
    • Associated with obesity, physical inactivity, family history
  • Signs and symptoms of diabetes include:
Signs and Symptoms of Diabetes
  • Risk factors:
Risk Factors for Diabetes
  • General Screening Criteria:
    • All patients with BMI greater than or equal to 25 kg/m2 + 1 risk factor
    • Children/adolescents with obesity + 1 risk factor
    • 45 years old if no risk factors are present
    • Pregnant women at 24-48 weeks
PrediabetesDiabetes
->Fasting plasma glucose (FPG) 100-125 mg/dL; or
->2-hour glucose after glucose tolerance test 140-199 mg/dL; or
->A1c 5.7-6.4%  		->Symptoms + random plasma glucose > 200 mg/dL; or
->2-hour glucose after glucose tolerance test > 200 mg/dL; or
->FPG > 126 mg/dL; or
->A1c > 6.5%  
  • Glycemic targets (per ADA guidelines):
    • A1c < 7%
    • 80-130 mg/dL pre-prandial plasma glucose
    • < 180 mg/dL post-prandial plasma glucose
    • A1c should be measured quarterly if not at goal
      • Or twice yearly if at goal
      • (A1c – 2) x 30 = average blood glucose
  • Drugs that may increase blood glucose levels:
Drugs that may increase blood glucose levels
  • Non-drug treatment options:
    • Smoking cessation
    • Weight loss
      • 3500 kcal weekly reduction = 1 lb weight loss
      • Waist circumference < 35 inches for females and < 40 inches for males
    • Nutrition
      • Carbs from vegetables, fruits, grains, and dairy
      • Omega-3 fatty acids and fiber
      • Limit saturated fat, cholesterol, and sodium
      • 15 g = 1 serving of carbohydrates
    • Physical activity
      • 150 min/week, moderate intensity
      • No more than 2 consecutive days off
      • Resistance training at least 2x/week
Drug treatments (oral medications)
  • Additional notes on oral drug classes:
    • Biguanides
      • Take with food
      • Use of alcohol increases the risk of lactic acidosis
      • Discontinue before any imaging with iodinated contrast; resume after 48 hrs
    • Meglitinides
      • Take 1-30 minutes before meals
      • If skipping a meal, skip dose as well
    • Sulfonylureas
      • Take with breakfast
        • Exception: Glipizide IR 30 minutes before breakfast
      • Glyburide – avoid in elderly and patients with renal impairment
    • Thiazolidinediones
      • Take with meals
      • May take weeks to take effect
      • Additional warnings:
        • Bladder cancer (pioglitazone only)
        • Risk of macular edema
        • Fracture risk
        • Hepatic failure
        • Resumption of ovulation
    • SGLT-2 Inhibitors
      • Caution when taking with diuretics and NSAIDs (due to risk of hypotension and acute kidney injury)
      • Additional warnings:
        • Genital infections
        • Hypotension
        • Increased LDL
        • Renal insufficiency
        • Ketoacidosis
      • Monitor K+ with Canagliflozin
    • DPP-4 Inhibitors
      • Take in the morning
Drug treatments (injectable medications)

Additional notes on injectable drug classes:

  • GLP-1 Agonists:
    • Exenatide and lixisenatide are administered 60 minutes before a meal
    • All others given without regard to food
  • Amylin Analog
    • Used in treatment of both type I and II diabetes
    • Reduce mealtime insulin by 50%

  • Drug treatments (Insulin)
    • For all insulins:
      • Side effects: weight gain
      • Warnings; hypoglycemia, hypokalemia
      • Never use pens for more than one individual
      • Most are 100 units/mL concentration
      • High risk medications
    • Dosing strategies
      • Basal insulin
        • Long or intermediate acting
        • Mainly affect fasting blood glucose
      • Bolus insulin
        • Rapid or short acting
        • Two purposes:
          • Prandial (mealtime) & correction (acute elevation)
Drug treatments (Insulin medications)
  • Insulins that do not require a prescription:
    • Regular insulin, NPH, and the premixed 70/30 combination
  • Insulin dosing for Type I diabetes:
    • Rapid-acting and basal insulin preferred
    • If using NPH and regular insulin
      • 2/3 NPH, 1/3 regular
    • Initiating basal/bolus insulin:
      • Calculate total daily dose (TDD)
        • 0.6 units/kg/day using TBW
      • Step 2: Divide TDD
        • 50% basal
        • 50% bolus
      • Step 3: Divide the bolus among 3 meals
    • Based on the amount of carbohydrates in a meal, meal-time insulin can be adjusted using rule of 500 (rapid-acting insulin) or rule of 450 (regular insulin)
      • (500 or 450)/TDD = g of carbs covered by 1 unit of insulin
  • Correction factor/dose
    • Factor:
      • Determines how much blood sugar will drop for every 1 unit of insulin. Uses the rule of 1800 (rapid-acting insulin) or rule of 1500 (regular insulin)
        • (1800 or 1500)/TDD = correction factor for 1 unit of insulin
  • Dose:
    • Amount of insulin required to bring blood glucose back to normal: [(blood glucose now) – (target blood glucose)]/   correction factor = correction dose
  • General treatment algorithm for Type II Diabetes:
General treatment algorithm for Type II Diabetes
  • For A1c greater than or equal to 8.5%: Jump straight to dual treatment
  • A1C > 10%: Think insulin
  • Cardiovascular benefit:
    • GLP1 agonists: liraglutide, semaglutide, exenatide
    • SGLT2 inhibitors: empagliflozin, canagliflozin
  • Patient-specific factors
    • Drugs that minimize hypoglycemia:
      • DPP4 inhibitor, GLP1 agonist, SGLT2 or TZD
    • Drugs that promote weight loss:
      • GLP1 agonist or SGLT2 inhibitors
    • Drugs with cost concerns:
      • Sulfonylurea or TZD
  • Combinations to avoid:
    • DPP4 inhibitors + GLP1
    • Sulfonylureas + insulin
  • Insulin dosing for Type II diabetes:
    • Initiate basal insulin after patient fails to reach or maintain goal on multiple oral therapies
    • Starting dose: 0.1-0.2 units/kg/day or 10 units/day
    • Titrate by 10-15% or 2-4 units once or twice weekly until fasting blood glucose at goal
    • If patient reaches fasting blood glucose goal but their A1c is still above goal:
      • Consider the addition of rapid acting mealtime insulin or GLP-1 agonist
  • Insulin administration:
    • Abdomen is the injection site (avoid belly button)
    • May also inject in thighs, buttocks, arms
      • Be consistent with administrations
    • Prime before each dose
    • Rotate sites
  • Hypoglycemia is common with insulin products, thus important to be aware of what to look out for and how to treat it
    • Defined as a blood glucose < 70 mg/dl
    • Symptoms: sweating, pallor, irritable, hunger, lack of coordination, sleepy
      • Beta blockers mask most except hunger and sweating
    • Treatment
      • Consume 15-20 g of glucose/simple carbohydrates
      • Recheck glucose levels after 15 minutes
      • Repeat if needed
      • Eat a small meal/snack to prevent recurrence
    • Glucagon is used only if patient is unconscious
  • Diabetes in pregnancy
    • Gestational diabetes: during pregnancy
      • Risks
        • Macrosomia
        • Hypoglycemia at birth
        • Obesity and type 2 diabetes
      • Management
        • Lifestyle modifications
        • Insulin added if needed (preferred)
        • Metformin and glyburide used
      • Goals:
        • Fasting < 95 mg/dL
        • 1-hour post-meal less than or equal to 140
        • 1-hour post-meal less than or equal to 120

We hope this review helped refresh your clinical knowledge on diabetes. Next up, we will take a look at dyslipidemia.

Best of luck,

Sam Tamjidi

RxPharmacist Team

References:

  1. National Diabetes Statistics Report, 2020. Centers for Disease Control and Prevention. https://www.cdc.gov/diabetes/data/statistics-report/index.html. Accessed October 26, 2020.
  2. Micromedex Solutions. Greenwood Village, CO: Truven Health Analytics. http://micromedex.com/. Accessed October 26, 2020.

A Brief Review on Hypertension for Pharmacists

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With so many organ systems, disease states, and medications to remember, preparation for the NAPLEX may often times seem like a daunting task. While there can be a considerable amount of material to go over for each clinical module, there are certainly some things that deserve more focus than others. This brief review will cover some of the most important information you need to know about hypertension when preparing for your upcoming exam.

General information:

  • Hypertension (HTN) is asymptomatic
  • HTN increases the risk for heart attacks, strokes, and kidney failure
  • Risk factors include the following:
    • High sodium and fat diet, physical inactivity, obesity, tobacco use, excessive alcohol consumption, genetics and family history, age, sex (women more likely than men), and race (African Americans more likely than any other race)
    • Drugs can also increase blood pressure, including the following:
      • Amphetamines, cocaine, pseudoephedrine, immunosuppressants, Nonsteroidal anti-inflammatory drugs (NSAIDs), steroids, ethanol, caffeine, serotonin and norepinephrine reuptake inhibitors (SNRIs), oral contraceptives, erythropoietin

Blood pressure categories:

 Ultimate blood pressure goal:

  • 130/80 mmHg

Treatments:

Four preferred drug classes for the following patient subgroups:

  • Non-African American: Thiazide diuretic, CCB, ACE inhibitor or ARB
  • African American: Thiazide diuretic
  • Patients with chronic kidney disease or diabetes with albuminuria ACE inhibitor or ARB
  • Initiate two drugs regimens if blood pressure is > 150/90 mmHg

Additional information:

  • ACE inhibitors, ARBs, Aliskiren
    • Do not use with Entresto
    • Do not use any combination of ACE inhibitors, ARBs, and aliskiren for treatment
  • CCBs
    • CYP3A4 substrates, avoid CYP3A4 inhibitors (eg, grapefruit)
    • Caution with ankle swelling and/or irregular heartbeat
    • Amlodipine and felodipine are the safest to use in patients with HF
  • BBs
    • No longer preferred for HTN treatment
      • Primarily used first-line for heart disease, post myocardial infarction, and HF
    • Use with caution when taking other drugs that decrease HR
    • Mask symptoms of hypoglycemia
  • Diuretics
    • Take doses in the morning or afternoon to avoid frequent urination symptoms at night
    • Provide K+ supplementation to compensate for decreased K+ levels
      • This does not remain true for K+ sparing diuretics
  • Hypertensive emergency
    • Blood pressure > 180/120 mmHg
    • Acute organ damage
    • IV medication used for treatment
      • Clevidipine, nicardipine, diltiazem, verapamil, enalaprilat, esmolol, labetalol, metoprolol tartrate, propranolol, nitroglycerin, nitroprusside, chlorothiazide
    • Goal is to decrease blood pressure by < 25% within first hour
  • Hypertensive urgency
    • Blood pressure > 180/20 mmHg
    • No organ damages
    • Oral medication for treatment
  • Pregnancy
    • Treatment with labetalol, methyldopa or nifedipine XR

Treatments (non-pharmacological):

  • Lifestyle modifications
    • DASH diet, limit salt intake (<1,500 mg/day), exercise, limit alcohol consumption, maintain proper weight (BMI between 18.5 – 24.9)

Be on the look-out for our next review, which will focus on diabetes.

Best of luck,

Sam Tamjidi

RxPharmacist Team

References: Micromedex Solutions. Greenwood Village, CO: Truven Health Analytics. http://micromedex.com/. Accessed October 12, 2020.

Pharmacy provider status – Are we there yet?

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The advancement of the pharmacy profession has allowed pharmacists to take on various roles and provide services that extend well beyond what people think. Often times, people think the role of a pharmacist may be assumed as the stereotypical 12-hour workday, consisting of only dispensing medications. However, pharmacists have gone to school for much more than to just dispense, and the magnitude of education and training received throughout school is pertinent to providing exceptional patient care throughout all types of pharmacy. As fellow pharmacists and pharmacy students, we all know too well that we have to go through a rigorous 4-year doctorate program. Pharmacists are now involved with advanced patient-centered services that include transitions of care, medication management, medication reviews with thorough monitoring, chronic disease management, disease education, prevention and wellness services, and patient education. To reinforce how essential they are, pharmacists have been amongst the frontline workers who have played a significant role in reducing the spread of the coronavirus disease 2019 (COVID-19). The extent to which accessibility of a pharmacist in one’s community took national stage when the Department of Health and Human Services (HHS) has authorized state-licensed pharmacists to order and administer, and state-licensed or registered pharmacy interns under the supervision of the pharmacist to administer, coronavirus disease 2019 (COVID-19) vaccines to individuals ages 3 or older. Without the efforts of implementing mobile testing facilities, composing response plans, providing curbside delivery, compounding hand sanitizers, and educating the public on methods to prevent spread, the nation’s population may have been much more vulnerable to its virulence. Their highly talented skills, in addition to reasonable accessibility, allows pharmacist to be trusted amongst patients. In fact, pharmacists are rated among the top 5 most trusted professionals year after year by Gallup.

What is provider status?

According to the Social Security Act (SSA), obtaining provider status means pharmacists can participate in Medicare Part B programs and bill Medicare for services under their scope of practice. However, at this time, and despite all their expertise, pharmacists are omitted from this status as the federal government does not consider these health care professionals as medical providers. Currently, those with provider status are professionals employed as physicians, physician’s assistants, certified nurse practitioners, qualified psychologists, clinical social workers, certified nurse midwives, and certified registered nurse anesthetists.

While a large component of this battle surrounds pharmacists fighting to gain provider status under Medicare Part B, reimbursement from Part D also appears to be controversial. Although Medicare Part D reimburses pharmacies for providing medication therapy management to select patients, the program includes only a small set of services that pharmacists are capable of supplying.

What barriers hold pharmacists from reaching this level of authority?

  • Congress members deliberately direct their focus towards the nation’s spending and other issues, including immigration.
    • Due to financial pressures, those making decisions are more focused on reducing health care expenditure, rather than adding new spending costs.
  • Congress equates provider status with the “fee-for-service” (FFS) payment model.
    • FFS is a model in which payment is contingent to the quantity of care, over quality.
    • Legislators may be unwilling to pursue old payment reform as newer payment models evolve.
  • Health care professionals with provider status who bill Medicare through the fee-for-service payment model are in a position of strength, both politically and financially.
    • These individuals may oppose the pharmacy provider status initiative.

While these barriers may impede the ultimate goal of gaining provider status, the American Pharmacist Association (APhA) is taking initiative by contacting health care providers, consumer organizations, payers, and policy makers, all in an effort to educate on the health and economic benefits a pharmacist provides.

What does this mean?

“Provider status is shorthand for ensuring that patients can get access to the clinical services that pharmacists provide and that pharmacists get reimbursed for providing those services” noted vice president of policy for the National Alliance of State Pharmacy Associations, Krystalyn K. Weaver, PharmD. Therefore, this exclusion limits Medicare beneficiaries from accessing pharmacist services.

Tom Menighan, EVP and CEO of APhA, also addressed this concern by stating: “Beyond being unfair to our profession, this lack of federal recognition restricts the contributions pharmacists can make to improving patient care.”

Why is this important?

There is an absolute need to improve health outcomes. In 2016, a released report revealed that the United States spends approximately $1.1 trillion annually on treatment for chronic health conditions, equivalent to almost 6% of the country’s GDP. Additional statistics include the following:

  • 1.5 million cases of preventable medication related side effects
  • $290 billion spent annually to treat preventable medication related side effects
  • $100 billion spent annually towards hospitalizations

Improvements in disease state management through proper medication use would not only go a long way in reducing these costs but will also advance patient quality of life in a cost-efficient manner. Who can serve this role and provide comprehensive education to help treat, manage, and prevent diseases? Pharmacists. All evidence through studies and practice-based experience has shown that pharmacists have all the tools to improve health outcomes and reduce health care costs; however, the absence of provider status and proper payment models have obstructed patients and health care providers from accessing full benefits received through pharmacist services. Provided below are opportunities that pharmacists have taken upon to increase health outcomes:

So, is now the time to gain provider status?

Amidst the ongoing global pandemic we face in today’s world, now is certainly the best time to gain full provider status. Currently, as of October 2020, there are only 37 states that have pharmacists classified as “medical providers” under the provisions of Medicare Part B, resulting in a lack of reimbursement for the clinical services provided. Being such an integral part of health care, pharmacists are well-equipped to take on much healthcare challenges, and COVID-19 is reassuring that certainty.

**October 2020 Legislation Update**

The Pharmacy and Medically Underserved Areas Enhancement Act (H.R. 592/ S. 109) is a bipartisan bill that will recognize pharmacists as providers under Medicare Part B. Furthermore, this bill will:

  • Allow Medicare beneficiaries to access the services provided by a pharmacist
  • Focus on providing pharmacist care and services to Medicare beneficiaries in medically underserved communities
  • Provide Medicare reimbursement for pharmacist services in medically underserved communities

Be a patron, support the cause, because now is the time to reward pharmacists for their purposeful work.

Best,

Sam Tamjidi

RxPharmacist Team

References:

  1. Gebhart, F. (2019, June 13). On the Road to Provider Status. Retrieved October 08, 2020, from https://www.drugtopics.com/view/road-provider-status
  2. Provider Status for Pharmacists. (2017, March). Retrieved October 10, 2020, from https://www.amcp.org/policy-advocacy/policy-advocacy-focus-areas/where-we-stand-position-statements/provider-status-for-pharmacists
  3. Provider status: What pharmacists need to know now. (2013, August). Retrieved October 07, 2020, from https://www.pharmacist.com/provider-status-what-pharmacists-need-know-now
  4. The Costs of Chronic Disease in the U.S. (2020, September 02). Retrieved October 07, 2020, from https://milkeninstitute.org/reports/costs-chronic-disease-us
  5. Weitzman, D. (2020, October 07). Provider Status for Pharmacists: It’s About Time. Retrieved October 08, 2020, from https://www.pharmacytimes.com/news/provider-status-for-pharmacists-its-about-time

NAPLEX or MPJE… Which one first?

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One of the most substantial fears that PharmD graduates face upon completion of pharmacy school surrounds the next step in their professional development: becoming a licensed pharmacist. With the exception of some states that require an additional practical exam, such as Georgia and New York, an individual must successfully obtain a passing score of 75% or higher on both their North American Pharmacist Licensure Examination (NAPLEX) and Multistate Pharmacy Jurisprudence Examination (MPJE) to become licensed to practice. While some have no preference in the order they wish to take their exams, others may be challenged with a relatively common dilemma – do I take the NAPLEX or MPJE first? This article will not necessarily state why you should pick one option over the other, but instead uncover things to consider when scheduling your exams.

Reason to take the NAPLEX first:Coming out of school, you may feel like a lot of what you have learned in class and during rotations is still relatively fresh in your mind. Before you switch gears to a completely different area of focus, you may want to tackle something you are more familiar with first. Also, depending on the school you have graduated from, you may have been required to register for Rxprep and take on assignments throughout your 4th year rotations, ultimately keeping your mind engaged on all clinical modules. Another reason is perhaps you have covered your law course during your third year instead of your fourth year of pharmacy school. Lastly, if your school does not provide any law prep course or support before you graduate.  
Reason to take the MPJE first:Based on the plethora of disheartening comments surrounding the exam, many previous exam takers can agree that the MPJE is a more difficult exam. Individuals who take the NAPLEX first may often feel burnt out after extensive preparation, thus leaving those who still have to take the MPJE mentally exhausted and devoid of motivation. Remember, pharmacy law is naturally perceived as a drier topic to begin with. Another reason is if your pharmacy school had you take a law course during your fourth year instead of third year, making the content fresher in your mind. Lastly, if your pharmacy school does provide a law prep course or support before you graduate.  

Our advice?

Ultimately what you decide is based on where you stand with respect to how comfortable you are with the content of each exam and even the urgency of addressing your financial situation. Also, depending on the institution, you may be a part of a residency program that grants you an additional couple of months of flexibility to become licensed. While it is fine to space out both exams to ensure adequate preparation, you should still be conscious of not distancing your exams too far apart. Remember, the goal is to promptly eliminate the last barrier that stands in the way of you becoming a licensed pharmacist and begin the take down of those horrifying student loans. This was why RxPharmacist was created in supporting pharmacy graduates and pharmacists to overcome the barrier of their licensure exams. Even more so, we also provide state-specific MPJE guides which is a unique offering among other known test-prep companies such as RxPrep which only offers NAPLEX and very minimal (and general) federal MPJE reviews. For more in-depth analysis and advice on each exam, please be sure to check out our previous blogs that provide excellent tips, things to consider, and resources to use to help you overcome your upcoming board exams:

Good luck!

Sam Tamjidi

RxPharmacist Team

Review of new and unique pharmacy careers

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It is undeniable that the role of a pharmacist has advanced from the traditional “pill counter” to trusted health care professionals who contribute to patient outcomes through extensive management of drug therapy. According to a published study by the American Association of Colleges of Pharmacy (AACP), the primary practice that PharmD graduates wish to pursue upon graduation is community pharmacy. To outline why this is relevant, the Bureau of Labor Statistics (BLS) anticipates a decline in employment for pharmacists within a traditional retail environment, thus posing a threat to many who wish to follow this route (our full post entitled, “Pharmacist market saturation and career outlook“ can be found here). While all of this may be concerning, pharmacists are fortunately well-equipped with suitable skills that allow them to rise above orthodox practice and pursue nontraditional opportunities while maintaining impactful frontline care. Favorably, the American Society of Health-System Pharmacists (ASHP) has acknowledged this matter and launched its Practice Advancement Initiative (PAI), providing pharmacists with future practice models that may act as an option for those exploring alternative career paths. The campaign advocates for advancing the role of a pharmacist by establishing changes to current pharmacy resources, ultimately promoting career opportunities and patient care simultaneously.

While the number of PharmD graduates continue to increase and advancement of traditional pharmacy begins to slow, you may be asking yourself “what other roles can be filled by pharmacists?” This article will dive into more nontraditional and innovative roles that remain both unique and effective in our dynamic health care world today.

Non-traditional career opportunities:

TypeDescriptionWhere to find information
Nuclear Pharmacy  Nuclear pharmacists focus on the preparation, monitoring, drug information, storage, and handling of radioactive medications. In addition to this, pharmacists in this role provide quality control, patient safety, and counseling to those who require a more unique class of medications. The need for a pharmacist within a nuclear medicine team is impeccable as it allows for a boost in pharmaceutical care to patients.  National Association of Nuclear Pharmacies (NANP)
Specialty PharmacySpecialty medications are typically referred to as high cost medications that focus more on intricate disease states such as cancer, transplant, hepatitis, HIV, and multiple sclerosis. The prevalence of patients who require specialty medication is increasing, thus necessitating an increased demand for specialty pharmacists who can provide comprehensive care and close management.   Due to the increased complexity in the delivery of specialty pharmaceuticals, many health plans have established approaches to help with the obstacles associated with the distribution of these drugs to patients (classified as insourcing and outsourcing):

Insourcing: Staff are hired to manage the high demand and cost of these medications. These pharmacists are responsible for purchasing, handling, educating physicians and patients, and monitoring patient outcomes.

Outsourcing: Contracting with pharmacies that have established specialty pharmaceutical services to access its expertise, technologies, and resources.   Regardless of the approach a managed care organization wishes to pursue, both insourcing and outsourcing have identical requirements that include: Negotiating discounted pricesEmploying staff with specific expertise (with respect to administration, utilization, and monitoring of specialty medications)Accessing centralized distribution points for specialty pharmaceutical manufacturers  		Academy of Managed Care Pharmacy (AMCP)
Veterinary Pharmacy  While veterinary pharmacy is not a new area of pharmacy practice, it is expected to expand each year and become classified as a more unique career opportunity. Veterinary pharmacists may establish a career with veterinary schools, pharmaceutical companies, manufacturers, and a variety of regulatory agencies (including the FDA through the Center of Veterinary Medicine). An individual interested in working with animals may make this a suitable option; however, additional education and training through residency is required and opportunities are limited usually to academic institutions or professional organizations.  Veterinary Pharmacy Association
Compounding Pharmacy  What originally began as physicians taking on both the prescribing and compounding role of patient medication has now evolved to become the responsibility of a pharmacist since the late 19th century. At one point, during the early progression of the 20th century, the manufacturing of mass medications monopolized the service of compounding pharmacies. Today due to the increased need to formulate patient-specific drugs to tailor drug therapy, there appears to be a resurgence in the demand for compounding pharmacists. Compounding services allow pharmacists to prepare medications that target pain management, dermatology, pediatrics, geriatrics, and hormone replacement therapy.  Alliance for Compounding Pharmacy  

APhA   National Community Pharmacists Association
Toxicology  Pharmacists in this role can serve as toxicology specialists within poison control centers. In these centers, they facilitate patients who have ingested or otherwise have been exposed to medications or household chemicals. Pharmacists will direct patients to the proper course of action and will subsequently follow-up with them depending on the severity of the situation.  American Association of Poison Control Centers
   TelepharmacyTelepharmacy aims to meet the needs of today’s healthcare consumers through the use of telecommunication. The application of this tool covers a wide and diverse scope, including drug review and monitoring, dispensing, sterile and non-sterile compounding verification, medication therapy management, patient assessment, patient counseling, clinical consultation, outcomes assessment, decision support, effective drug information, and electronic prescription filling. Telepharmacy technology allows pharmacists to provide communication and remote care delivery. It significantly improves quality of patient care and medication process and safety by increasing accessibility and efficiency through reducing the need to travel. Especially during the ongoing pandemic, telepharmacy has established itself as an attractive tool to positively impact patient outcomes. Individuals who have been tested for COVID-19 could have a consultation with the pharmacist on the phone or video conferencing platforms such as Skype or zoom for follow-up care. Telepharmacy aims to improve U.S. economy and healthcare efficiency.  ASHP’s Statement on Telepharmacy  
2019 NIH Study on Telepharmacy
Regulatory Sciences  Pharmacists also play a huge role in regulatory drug and biologic development at the Food and Drug Administration (FDA). Many pharmacists work at the FDA and if you are lucky, you may score a rotation site at the FDA to learn more what they do from drug labels, to drug reviews and ensuring regulations are met.  FDA Regulatory Fellowships  

Regulatory Affairs Professionals Society (RAPS)  

While additional opportunities may require fellowship training, pharmacists can also be involved within the pharmaceutical industry and strive in research and development, quality assurance, marketing, and regulatory affairs. There are still many other pockets of careers we did not dive into such as medication therapy management (MTM), pharmaceutical industry, consulting, and data analytics, the PharmD degree is versatile and allows the flexibility of pharmacists to create their own unique careers outside the ‘box’ of retail and hospital pharmacy. As health care transforms, pharmacy roles will also grow, allowing pharmacists to take on new and unique roles.

Best of luck in your career searches!

Sam Tamjidi

RxPharmacist Team

References:

  1. 6 Things to Know About Telepharmacy During COVID-19. (n.d.). Retrieved September 26 2020, from https://blog.cureatr.com/6-things-to-know-about-telepharmacy-during-covid-19
  2. ASHP Statement on Telepharmacy. (n.d.). Retrieved September 26 2020, from https://www.ashp.org/-/media/assets/pharmacy-informaticist/docs/sopit-bp-telepharmacy-statement.ashx
  3. Bai, S., Hertig, J. B., & Weber, R. J. (2016). Nontraditional Career Opportunities for Pharmacists. Hospital pharmacy, 51(11), 944–949. https://doi.org/10.1310/hpj5111-944
  4. Kramer, M.H. (2019, January 14). Retrieved September 22, 2020, from https://www.thebalancecareers.com/veterinary-pharmacist-125836
  5. Specialty Pharmaceuticals. (July 18, 2019). Retrieved September 27 2020, from https://www.amcp.org/about/managed-care-pharmacy-101/concepts-managed-care-pharmacy/specialty-pharmaceuticals
  6. What is compounding? (n.d.). Retrieved September 22, 2020, from https://www.medisca.com/compounding/what-is-compounding

Career advancement opportunities – Residency or fellowship?

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Over the last decade, the profession of pharmacy and the capabilities of a pharmacist has advanced immensely with respect to broader clinical responsibilities and logistical needs in the Pharma industry. We previously lived in a time where a bachelor’s degree in pharmacy sufficed for a career in pharmacy practice. Since 2003; however, the Doctor of Pharmacy (PharmD) degree has superseded previous qualifications to become a licensed pharmacist and has provided pharmacists more holistic roles as a healthcare provider. To dive deeper, the role of a pharmacist now extends from the initial introduction of a chemical molecule for drug therapy all the way to managing a patient’s regimen post dispensing. Based on the competitiveness and saturation of the workforce, in addition to employment projections showing decreased future demand for retail pharmacists (as previously mentioned in our Pharmacist market saturation and career outlook blog here), it is presumed by many that a PharmD will simply be a stepping stone within the realm of pharmacy practice. Therefore, the well-rounded ability needed for our future pharmacists will strongly build through residencies and fellowship.

What are some opportunities to differentiate yourself as a newly graduate? Let’s take a look at the following main categories of post-graduate training programs:

Residencies:

  • Focus primarily on direct patient care
  • Within a clinical, hospital, or community setting
  • Collaborate with pharmacists, nurses, and other healthcare professionals
  • Duration: 1 year each – Postgraduate Year One and Two (PGY1 and PGY2)
    • PGY1 – General medicine
    • PGY2 – Specialized therapeutics
      • Specific areas of focus include: Ambulatory care, cardiology, critical care, geriatric, pediatric, oncology, pain management, and more. For a more complete list of options, be sure to check out American Society of Health-System Pharmacists’ (ASHP) website.
    • Interestingly enough, the perception of a PGY3 residency has been viewed negatively by many pharmacists. Based on a distributed survey, residents, preceptors, coordinators, and other pharmacists believe that PGY3 training offers limited benefits in professional development.
  • Career after completion: Hospital or clinical pharmacist

While clinical and hospital settings are more predominate, many also choose to pursue community-based residency programs. This path allows residents to remain within the community setting while taking on critical education and training to provide increased care and improve patient outcomes.

Another popular residency of interest is managed care. Managed care residencies heavily focus on evidence-based clinical decision-making and comparative research, medication therapy management, clinical drug evaluation, formulary management, quality assurance, and drug utilization review. A pharmacist within these roles is responsible for performing any analysis, for example, drug utilization data to identify trends and then implement new strategies to improve patient outcomes. Additionally these roles may also require on-going knowledge of all heath plan pharmacy benefits. Beyond the logistical aspects of analyses, clinical knowledge is key for a successful career in managed care. Managed care pharmacists are also part of multidisciplinary teams during rounds in which they serve as the primary drug information resource, provide pharmaceutical interventions, facilitate prior authorizations, and develop educational materials for patients and providers.

What’s the likelihood of matching?

Below is a graphical representation of the match statistics between 2013-2020. Figure 1 illustrates the amount of applicants participating in the match, positions offered, matches/positions filled, unmatched applicants, and unfilled positions. Based on the trend, it’s easy to interpret that residency is playing an expanding role as more programs are being introduced each year. While this appears to be beneficial, it’s also important to address the increasing applicant pool, making it a challenging to gain acceptance in the program of your choice.

A close up of a map Description automatically generated
Figure 1. Complete match statistics between 2013-2020.

Fellowships:

  • More research and data-based
  • Within the pharmaceutical industry, academia, nontraditional pharmacy or healthcare setting
  • Collaborate with professionals, both in and out of healthcare
  • Duration: Ranges between 1-3 years depending on the program
  • Career after completion: Pharmaceutical industry or academia

It is very clear that these two main options provide two distinct pathways. The direction you wish to pursue will strictly depend on your interests. If you thoroughly enjoyed classes that focused on therapeutics, pharmacology, and kinetics throughout pharmacy school then a residency may be the best option for you. Conversely, if you were more engaged on the economics, research, and administrative science side of pharmacy, then a fellowship would be better suited for you. Whether you wish to enhance your clinical knowledge or look for professional advancement, a residency or fellowship will provide a firm foundation and present you with many unique career opportunities down the road.

What can you do now and what are some additional resources to find out more?

  • Take a moment to fill out the APhA Career Pathway Evaluation Program for Pharmacy Professionals survey. This quiz will aim to assess your goals, values, strengths, likes, and dislikes.
  • Maximize your potential and showcase your academic achievements while demonstrating your leadership qualities outside of the classroom.
  • Check out the ASHP and ACCP directories to get a better idea of the many residency and fellowship opportunities out there and which institute may best suit you.

Whatever you wish to do is ultimately your decision. All we recommend from our end is to be the best version of yourself and manifest all your skills in an effort provide to the pharmacy profession.

Good luck!

Sam Tamjidi

RxPharmacist Team

References:

  1. Dang, Y. H., To-Lui, K. P. (2020). Pharmacist perceptions of and views on postgraduate year 3 training. American Journal of Health-System Pharmacy, 77(18), 1488-1496. doi:10.1093/ajhp/zxaa198
  2. Doctor of Pharmacy. (n.d.). Retrieved September 19, 2020, from https://en.wikipedia.org/wiki/Doctor_of_Pharmacy
  3. Goode, J. R., Owen, J. A., Bennett, M. S., &amp; Burns, A. L. (2019). A marathon, not a sprint: Growth and evolution of community-based pharmacy residency education and training. Journal of the American College of Clinical Pharmacy, 2(4), 402-413. doi:10.1002/jac5.1140
  4. Postgraduate Education Frequently Asked Questions: Residencies and Research Fellowships. (n.d.). Retrieved September 17, 2020, from https://www.pharmacist.com/sites/default/files/files/10-417postgraduate.pdf
  5. Tips on Applying for a Residency or Fellowship. Academy of Managed Care Pharmacy. (n.d.). Retrieved September 19, 2020, from https://www.amcp.org/resource-center/group-resources/residents-fellows/tips-on-applying-residency-fellowship

Pharmacist market saturation and career outlook – An overview

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One of the main obstacles that recent PharmD graduates face is the challenge of finding a job right out of school. Whether it is due to saturation or a lack of experience, the dynamic field of pharmacy appears to raise concern for many, and statistics appear to support this concern. According to the U.S. Bureau of Labor Statistics (BLS), which is responsible for publishing employment trends and projections, there is an estimated 3% decline in pharmacist employment between 2019 and 2029. While the career outlook of a pharmacist may vary by industry, it is quite evident that most of this decline comes from chain and independent pharmacies (Table 1).

Table 1. Employment projections for pharmacists in a retail versus non-retail setting.

Table 1 above accounts for 81% (or 259,000 of 321,700) of jobs that pharmacists have held in 2019, while the remaining 19% come from other industries that have a positive effect on the pharmaceutical workforce. A more detailed look at employment projections can be found here.

What can we take home from observing these statistics? The demand for pharmacists who work in non-retail settings, such as hospitals and ambulatory care facilities, is set to increase over the next decade as the number of jobs are expected to grow. Alternatively, all retail positions, which make up over half of all pharmacy jobs, is projected to take a significant hit and decline over the next 10 years. Why might this be the case? This branch of pharmacy is expected to expand the role of pharmacy technicians and transition to greater use of mail order and online pharmacies. For example, marketed as “a better, simpler pharmacy”, Amazon has expanded pharmacy by introducing their PillPack and in September 2020, launched its online pharmacy in India. This online service is free and allows patients to receive free delivery on their prescriptions and over-the-counter medications monthly, reducing the need to sort their meds, wait in line, or chase refills.

How could you respond and move forward?

  • Build connections: Use platforms such as LinkedIn to expand your social network and connect and communicate with those in the same profession. Reach out to your school’s alumni network as you already have a shared connection of your alma mater to start off the conversation.
  • Be comfortable with being uncomfortable: Often you may find more opportunities outside of your city or state of preference. While this may seem unfavorable to begin with, coming out of you comfort zone will always pay off.
  • Be innovative and embrace change: Demonstrate your passion for excelling the pharmacy profession and show your willingness to flourish. Opportunities will come by with the right mindset.

As always, best of luck!

Sam Tamjidi

RxPharmacist Team

References: Pharmacists: Occupational Outlook Handbook. (n.d.). Retrieved September 09, 2020, from https://www.bls.gov/ooh/healthcare/pharmacists.htm

How to pass your NAPLEX the first time

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Congratulations, you made it through pharmacy school and officially graduated! Now, you may find yourself consistently browsing through articles and student forums across the web, all in hopes of finding the best tips for succeeding in your upcoming licensure exam(s). The NAPLEX has undeniably become more challenging over the years. Changes were made to the exam back in 2016, ultimately resulting in decreased pass rates since then (Table 1).

YearPassing Rate (%)
201494.9
201592.6
201685.9
Table 1. First-time NAPLEX Pass Rates for 2014-2016

With the exception of the brief increase in passing rates seen in 2018, scores remain consistently low since 2016 (Table 2). Is the exam becoming more clinical? Are school curriculums becoming outdated? Or are exam writers simply burning out due to the extended length and duration of the NAPLEX? There could be a variety of reasons as to why pass rates have dropped, and while preparing for an exam that covers up to 4 years of material may feel overwhelming, this article will pinpoint everything you need to know to overcome these statistics and take down your NAPLEX exam (also be sure to check out tips on how to pass your MPJE from our RxPharmacist blog here).

YearPassing Rate (%)
201786.28
201888.03
201986.74
Table 2. First-time NAPLEX Pass Rates for 2017-2019
  1. The first step in preparing for any exam is familiarizing yourself with it .

The NAPLEX is 6 hours long and contains 250 questions; 200 count towards your score, while the remaining 50 questions anonymously serve as experimental questions and will have no effect on your score. Many of the questions you’ll come across will be written as patient cases and will require you to piece together multiple elements of the information provided. Questions are presented in multiple choice, select all that apply, fill-in-the-blank (for calculations), ordered response, and hot-spot (using a diagram to identify the answer) format.

The NAPLEX is broken into two major areas:

  • Area 1: Ensure Safe and Effective Pharmacotherapy and Health Outcomes (67%)
  • Area 2: Safe and Accurate Preparation, Compounding, Dispensing, and Administration of Medications and Provision of Health Care Products (33%)

Each one of these areas are further broken down into more detailed subcategories that are listed as part of the NAPLEX competency statements found here from NABP’s website.

  • Once you know the basis of the exam, the next important item on your checklist is to implement a study schedule that strictly predetermines your daily and weekly goals. As much we’d like to provide an estimate on how much time you should set aside to study, the only person who is best aware of their tendencies and abilities is you. Be realistic and fair with your timeline and be sure create an effective study environment by setting aside all distractions during study periods.
  • In terms of study resources, Rxprep has become well-reputable throughout its time and many have relied on the course book as it covers each topic in depth and provides effective illustrations. Rxprep can definitely be a primary tool for studying, but not the only one.

Other helpful resources include:

  • Quizlets: Online flash cards that can serve to enhance and encourage quick recall.
  • RxPharmacist’s practice questions: One of the most updated guides that contains over 500 NAPLEX practice questions that highly mimic the actual exam.
  • Medication and disease state charts: Will help condense information down to the most important material you need to know – excellent tool to use for review. Our RxPharmacist CPJE exam guide provides a nice review of all of the major clinical topics with visuals and easy to read charts.

One thing we’d like to place emphasis on is the importance of practicing calculations. A considerable portion of the exam contains calculations, which are typically very easy to answer if you’re familiar with the formulas and procedures. Consistent practice will help make you an expert in calculations, allowing for a little more leeway when you come across the more tedious and difficult clinical questions. This is why our RxPharmacist NAPLEX guide has a heavy amount of difficult practice calculations so you can easily breeze through the calculation portion to score as high as possible in boosting your overall score.

Similar to the MPJE, the questions on the NAPLEX can be detailed and require thorough reading. Be sure not to rush through the exam and be mindful of what the question is asking.

Best of luck!

Sam Tamjidi, PharmD

RxPharmacist Team

References:

  1. Score Results. (n.d.). Retrieved August 27, 2020, from https://nabp.pharmacy/programs/naplex/score-results/
  2. Welch, A. C., & Karpen, S. C. (2018). Comparing Student Performance on the Old vs New Versions of the NAPLEX. American journal of pharmaceutical education, 82(3), 6408. https://doi.org/10.5688/ajpe6408

How to Pass Your MPJE Exam the First Time

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Each year, the NABP composes a list of MPJE pass rates for each school and college of pharmacy in the United States and compares these results to previous years. While the goal is to observe an upward and promising trend in pass rates, the data obtained between 2017-2019 indicates otherwise, as illustrated in the figure below. Cumulative pass rates across the United States have declined from 83.98% to 81.9% over the last couple of years and while the difference may not appear significant, any outcome that does not demonstrate improvement is unfavorable and must be addressed.

Data Reference: NABP website

What could be the result for the decline in performance? Increased burnout? Increased competition? Poor pharmacy coverage of law? Regardless what the case may be, studying for the MPJE is a tedious process. You may not know what to do or where to begin; however, there are many tips and resources that may be useful to make you feel more prepared for your upcoming exam.

There are no shortcuts and a lot of time and effort must be devoted to preparing. In this article, we attempt to help you understand the highlights of the MPJE and how to pass it the first time.

Know what the exam is about.

The MPJE requires a passing score of 75% or higher. It is constructed as a 2.5-hour exam that is composed of 120 questions with three areas of focus, including:

  • Pharmacy practice (83%)
  • Licensure, registration, certification, and operational requirements (15%)
  • General regulatory requirements (3%)

The exam aims to assess an individual’s competency by testing their knowledge and skills in evaluating situations and applying relevant federal and state laws. Knowing the build-up of the exam can be a useful marker in indicating how much time should be devoted to each section. A greater breakdown of each area of focus can be found on NABP’s website here. All questions are in multiple choice, select all that apply, K-type (I only, II and III, or I, II, and III), and ranking format. Be prepared to choose the best answer(s).

Use appropriate study materials.

Unlike preparing for the NAPLEX, which is typically associated with review of one extensive guide, preparation for the MPJE is a little different in that it does not have its own “go-to” guide. RxPharmacist noticed this concern and took action by erasing the dilemma of what resource to use. Here are some tools to help you pass on your first try:

  • Both the state laws and rules can be found on your Board of Pharmacy website. We recommend going to your Board of Pharmacy website first, and if you need help, then pursue study guides as another resource.
    • If you choose to review all the content on the Board’s website, be sure to take notes while you read. The material can be quite extensive as a whole but reducing it into your own writing will serve as an excellent source when the time comes to do your final review before your exam.
  • RxPharmacist provides detailed study guides (in both online and print format) that target key points the MPJE generally focuses on. These comprehensive guides cover both federal and state pharmacy law while providing plenty of questions for practice. To see if a guide is available for your state, check out all the courses provided here.
  • Guide to Federal Pharmacy Law, 9th Edition provides an excellent review of federal law applicable to the exam. The limited use of legal jargon allows for a smoother read while focusing on the most pertinent information.

Whether you choose to study all the material from your Board of Pharmacy’s website or purchase a study guide for a smoother ride, there are a series of topics that must be focused on and highlighted, such as the following:

  • Prescription/labeling requirements
  • Controlled substances
    • DEA forms
    • Classification of controlled substances
    • Prescribing authority and filling
    • Emergency/partial fills
    • Expiration
    • Transfers
    • Refills
  • Other
    • Compounding
    • Continuing education
    • Drug utilization reviews
    • Adulterated vs. misbranded
    • LTCF/hospice facilities
    • Emergency kits
    • Immunizations

Practice, Practice, and Practice!

It’s one thing to study all the material, but it’s an entirely different element to apply all the content you learned to patient scenarios. You won’t realize how challenging it is to distinguish between multiple answer choices until you practice, and thus application is crucial. Some of the highlighted study material listed above can provide you with practice questions; however, additional resources to maximize your practice can be found on NABP’s website.

Another great way to test yourself is with the use of flash cards!

Additional tips:

  • Create a schedule and routine for yourself. Every person is different, thus being aware of your study habits is critical in allowing yourself appropriate time to prepare.
  • Remember to put aside your biased work experience and not depend on everything you see during your workdays such as in the retail pharmacy setting. Sometimes there are differences between what the law states and what your company’s policy is.
  • As the exam does not specify between state and federal law, always pick whichever law is stricter.

Keep in mind the questions on the MPJE can be detailed and require thorough reading. Be sure to not rush through the exam and be mindful of what the question is asking.

Good luck!

Sam Tamjidi, PharmD

RxPharmacist Team

References: MPJE Score Results. (n.d.). Retrieved August 27, 2020, from https://nabp.pharmacy/programs/mpje/score-results/

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