Happy Holidays and Happy New Year. It seems like only yesterday I was serving as WMSHP president for the first time. It has actually been 5 years! Time does fly. I am pleased to be serving as your WMSHP president once again.

You will see a mix of new and familiar faces within the leadership of WMSHP this year. The WMSHP leadership for 2013 is as follows:

• President: Dana Staat (Spectrum Health)
• Past-President: Kali VanLangen (FSU)
• President-Elect: Angela Green (Mercy)
• Treasurer: Kim Melgarejo (Borgess)
• Secretary: Brad Miller (Spectrum Health)
• Technician: Ciji Marckini (Spectrum Health)
• Returning Board Members: Kasey Bucher and Abby Sturm (Saint Mary's), Kari Vavra and Kristina Rak (FSU)
• New Board Members: Becky Maynard (Borgess), Michael Michutka (Borgess), Katie Axford (FSU), and Carrie Morrison (Mercy).

Our next meeting will be held January 10, at Borgess Medical Center-Lawrence Education Center Auditorium. Donald Scott, Pharm.D. , Infectious Disease Clinical Pharmacist at Spectrum Health, will be speaking about antimicrobial dosing in the obese patient.

Save the date: The WMSHP Spring Seminar will be held May 7, 2013 at the Prince Conference Center on the campus of Calvin College in Grand Rapids.

The last WMSHP Meeting of 2012 is just around the corner!! Make sure to RSVP early!

Not only is November our last meeting of the year, but it is also time to vote for who our incoming Board Members are going to be. Watch for your ballot to arrive and return it to any Board Member to make sure your vote is counted.

As a reminder, monthly meetings will resume in January.

Also, we are starting to plan for the 2013 WMSHP Spring Seminar. If you have ideas or topics you would like to hear about please send me an email at KaliVanLangen@ferris.edu.

Finally, thank you to all of the members of WMSHP for allowing me to serve as your President for the past year. I have enjoyed the experience and look forward to serving as Past President in 2013 and planning our annual Spring Seminar Meeting. I would also like to welcome Dana Staat as President for the 2013 year and for agreeing to serving for a second time!

The cooler temperatures and shorter days means Fall has arrived and WMSHP is back in full swing.

WMSHP is hosting two events this month and both events are being held on October 18. The first event is our monthly meeting. Shawna Kraft, PharmD from the University of Michigan will be presenting on "Oncologic Emergencies" at this month's meeting which is being held at the Lawrence Education Center auditorium on the campus of Borgess Medical Center in Kalamazoo.

The second event is our annual Residency Showcase. This year, the residency showcase is being held at Ferris State University's new College of Pharmacy building located at 25 Michigan Ave in Grand Rapids. Many programs from around the state will be in attendance. Pharmacy students are welcome to attend and learn more about the residency programs in our area.

This is the time of year that WMSHP is also looking for members to volunteer their time as a Board Member. Board Members serve 2 years terms and are primarily responsible for planning one monthly meeting for each year they are on the board. If you are interested in adding your name to the ballot for Board Member, please notify any current Board Member by October 12, 2012.

Also, we are starting to plan for the 2013 WMSHP Spring Seminar. If you have ideas or topics you would like to hear about please send me an email at KaliVanLangen@ferris.edu.

Let the search begin! The time has come to begin the search for the 2012-2013 residency class. Western Michigan Society of Health-Systems Pharmacists will be holding a Residency Showcase in conjunction with Ferris State University on Thursday, October 18th. The showcase is scheduled to commence at 5:30 pm and will be held at the Ferris State University College of Pharmacy, 25 Michigan St NE, Grand Rapids, MI, Room 713.

Please RSVP via e-mail to Angela Green by Thursday, October 11th to secure your place in the showcase. The cost for a program to participate in the showcase is $30 and payment can be made online or at the showcase. There is no charge for residency candidates who would like to attend and view the showcases.

As the date of the Residency Showcase approaches, we will contact registered programs with important information needed regarding set-up and parking.

If you have any questions, feel free to contact Angela Green by phone at (231) 672-4929 or via e-mail at greenak@trinity-health.org

Welcome back to another season of WMSHP meetings! The end of summer means the beginning of monthly CE programs for WMSHP members. In keeping with last year's format, we will be hosting the majority of monthly meetings at our institutions to help control the cost, however; Board Members approved for one meeting to be held in a restaurant in each our two main cities, Grand Rapids and Kalamazoo.

Our first speaker to help us get back into the swing of things in John Jameson, PharmD. As many of you know, John is faculty member at Ferris State's College of Pharmacy and always brings a wealth of experience all of his presentations. This year, John's presentation is titled "Insulin: First Do No Harm" and will discuss the key concepts to help optimize insulin therapy in our patients.

WMSHP and Ferris State University will also hosting it's annual Residency Showcase this October. More details will be coming soon!

The recent record setting temperatures have most people enjoying backyard barbeques and fun in the sun.  But don’t forget to enjoy the wonderful things Spring has to offer including the last two meetings before WMSHP takes a break from monthly meetings to enjoy the summer.

Be sure to join WMSHP on Friday, April 13 to support two area pharmacy practice residents as they each present their residency project.   The scheduled presenters and their project titles are listed below.

• “A comparison of extended infusion versus traditional infusion piperacillin-tazobactam: a retrospective study”, presented by Katie Wenzel, PharmD (Bronson Methodist Hospital)

• “Evaluation of Fixed Dose Recombinant Factor VII for Warfarin Reversal in Neurosurgical Patients”, presented by Gregory F. Blank II, PharmD (Spectrum Health)

Immediately following the presentations, join us at the last Grand Rapids Griffins game of the year at Van Andel Arena.  Family and friends are welcome to attend the game.  More information on how to order tickets is available on the meeting's RSVP page on WMSHP.net.

WMSHP is still accepting applications for the annual WMSHP Scholarship.  This year, one $1,000 scholarship will be awarded.  Deadline for scholarship applications is March 31, 2012.

Save the Date
Don’t forget to mark your calendar for WMSHP’s Spring Seminar scheduled for Monday, May 14, 2012 at the Prince Conference Center on the campus of Calvin College in Grand Rapids.  Registration should be available soon!

As I watched my dog run around our yard this morning, I was able to take a minute and realize that February is almost over and the signs of spring are all around. The snow has melted, the days are growing longer, and my flowers are starting to grow. With spring right around the corner, WMSHP is getting ready for our busiest time of the year.

Our next meeting will be held on March 15 at the Lawrence Education Center Auditorium on the campus of Borgess Medical Center. Tracey Mersfelder, PharmD will be presenting a topic entitled "Grow to Your Health".

Congratulations to Katie Wenzel and Gregory Blank II! Dr. Wenzel and Dr. Blank were selected by the board out of over 20 entries to present their residency projects at our meeting on Friday, April 13 to be held at the last Grand Rapids Griffins game of the year. Mark your calendars and watch for the RSVP to come out earlier than usual so that we can ensure enough seats for everyone who wants to attend. Family and friends are welcome!

WMSHP is now accepting applications for the annual WMSHP Scholarship. Deadline for scholarship applications is March 31, 2012.

Well, it appears Old Man Winter did not forget about us after all. Snow and frigid temperatures are back and winter has officially begun but that isn't stopping WMSHP.

The January meeting resulted in good attendance and a very informative talk on heart failure by Dr. Michael Mitchuka. Despite the threat of dangerous roads and heavy snowfall, many members were able to attend. I can only hope for similar results for the remainder of the winter months.

Brad Miller, PharmD will updating us on recent happenings in Emergency Medicine. The meeting will be held at Saint Mary's Lacks Cancer Center on February 9.

Attention Pharmacy Residents!  Don't forget to submit your Great Lakes Project abstract to WMSHP if you would like the opportunity to present your project to our members at our April meeting. Two residents will be selected to present their projects on Friday, April 13 prior to everyone attending the last Grand Rapids Griffins game of the year. This is a great opportunity to practice your presentation before attending the Great Lakes Conference.

In the January 2012 WMSHP Newsletter, Chelsey Timmer, a PGY1 pharmacy resident at Spectrum Health, writes about therapy for suspected cyanide poisoning.

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Use of Cyanokit^® for Suspected Cyanide Poisoning

Chelsey Timmer, Pharm.D.

Poisoning due to cyanide can cause severe harm and death within minutes to hours. For this reason, it is critical that clinicians are aware of common sources of cyanide exposure. Exposed patients must be quickly assessed for signs and symptoms of toxicity, and clinicians must be able to identify how and when to appropriately use the available cyanide antidotes.

The major source of cyanide exposure in the United States is via smoke inhalation from structural fires^1,2,3. Cyanide gas is produced when materials such as wool, silk, polyurethane, and synthetic polymers combust². During a fire, inhaled cyanide gas can rapidly diffuse into tissues, causing signs and symptoms of toxicity within minutes. Other sources of cyanide poisoning include intentional ingestion in an attempt to commit suicide, accidental ingestion, and occupational or industrial exposures to the chemical. The anti-hypertensive medication sodium nitroprusside, which contains 44% cyanide by molar weight, can also lead to cyanide accumulation in select patient populations such as those with a defect in cyanide metabolism or renal dysfunction¹.

Cyanide binds to the ferric ion of cytochrome oxidase a₃, a component of the mitochondria that is essential for oxidative phosphorylation. When cyanide levels rise, the normal elimination pathway is overwhelmed, oxidative phosphorylation is inhibited, and levels of lactate rise to cause a metabolic acidosis^1,4. This may manifest initially as an anxiety, headache, giddiness, tachycardia, and tachypnea. As the toxicity progresses, hypotension, arrhythmias, seizures, and coma may occur^1,3.

It is imperative that practitioners recognize that cyanide exposure needs to be assessed and promptly treated. The two antidote kits currently available for treatment are the cyanide antidote kit and Cyanokit^®. Quick Drug References are available on Insite for both products^5,6. The cyanide antidote kit consists of 3 drugs: amyl nitrite, sodium nitrite, and sodium thiosulfate. Amyl nitrite is to be administered via inhalation while IV access is obtained; if IV access is already established, sodium nitrite should be administered first. Amyl nitrite and sodium nitrite work to oxidize hemoglobin to methemoglobin. Cyanide will preferentially bind to methemoglobin, freeing cytochrome oxidase a₃ and allowing the resumption of ATP generation and cellular respiration. Sodium thiosulfate is administered immediately following sodium nitrite. It facilitates excretion by acting as a sulfhydral group donor to cyanide. This forms the compound thiocyanate, which is renally eliminated^1,5.

The cyanide antidote kit is associated with multiple adverse events as well as administration difficulties, making it the non-preferred treatment for cyanide poisoning. The major side effect is hypotension, due to both the nitrites and the sodium thiosulfate portions of the kit. Sodium nitrite should be administered slowly over at least two minutes, and sodium thiosulfate over at least 10 minutes to minimize the risk of hypotension. The production of excessive amounts of methemoglobin can also be concerning in patients who may already have low levels of functioning hemoglobin due to concurrent carbon monoxide poisoning. Patients should be observed for signs of methemoglobinemia, including a blue color of the skin or mucus membranes, vomiting, shock, and coma⁵.

Cyanokit^®, which contains hydroxocobalamin, is the preferred treatment for suspected cyanide poisoning due to its comparative ease of administration and less severe side effects. Hydroxocobalamin works by binding to cyanide to form cyanocobalamin (vitamin B₁₂). Cyanocobalamin is renally eliminated, freeing cytochrome oxidase a₃ for cellular respiration. Each Cyanokit® contains two 2.5 g vials of hydroxocobalamin, two sterile transfer spikes, and one sterile intravenous infusion set. The starting dose for adults is 5 g (two 2.5 g vials), which should be reconstituted in 200 mL 0.9% sodium chloride. A second dose of 5 g may be administered if signs and symptoms of cyanide poisoning persist. For children, the starting dose is 70 mg/kg IV. The first dose should be administered over 15 minutes, the second dose over 15 minutes to 2 hours⁶.

Side effects of hydroxocobalamin include discoloration of skin and body fluids as well as hypertension. In a prospective, open-label trial, diastolic blood pressure increased by an average of 10 mmHg, while systolic increased an average of 7.5 mmHg. This transient increase may actually benefit patients who are hypotensive due to cyanide poisoning. Blood pressure returned to baseline without treatment in all patients³. Red discoloration of the skin and urine are the most common side effects of hydroxocobalamin. Skin redness may last up to 2 weeks, urine redness up to 5 weeks⁶. Hydroxocobalamin can also interfere with colorimetric laboratory tests, including bilirubin, creatinine, magnesium, serum iron, oxyhemoglobin and methemoglobin¹.

Whether or not to empirically treat fire victims for cyanide poisoning is a long-debated issue, with some clinicians arguing that cyanide poisoning is over-diagnosed and treated, and others in favor of treating all patients who have potential symptoms of cyanide poisoning². One reasonable approach is to administer hydroxocobalamin to any patient who has been in a structural fire and has mental status changes. If it is an available service, toxicology should also be consulted for these patients.

References

1. Hammel J. A review of acute cyanide poisoning with a treatment update. Crit Care Nurse. 2011 Feb;31(1):72-82.
2. Barillo DJ. Diagnosis and treatment of cyanide toxicity. J Burn Care Res. 2009;30(1):148-152.
3. Borron SW, Baud FJ, Barriot P, Imbert M, Bisumth C. Prospective study of hydroxocobalamin for acute cyanide poisoning in smoke inhalation. Ann Emerg Med. 2007 Jun;49(6):794-801.
4. Hall AH, Dart R, Bogdan G. Sodium thiosulfate or hydroxocobalamin for the empiric treatment of cyanide poisoning? Ann Emerg Med. 2007 Jun;49(6):806-813.
5. Posey J, Thomas W. Amyl nitrite, sodium nitrite, sodium thiosulfate kit (Cyanide Antidote Kit®). Spectrum Health Drug Quick Reference. Updated 2011 Jan; pp 1-2.
6. Posey J, Thomas W. Hydroxocobalamin (Cyanokit®). Spectrum Health Drug Quick Reference. Updated 2011 Jan; pp 1-2.

The holidays are upon us once again and it is hard to believe that another year is over. As we get ready to welcome 2012, it is also time to welcome a new set of board members to the WMSHP family.

First, I would like to welcome back Dana Staat as President-Elect. Dana served as WMSHP president in 2008 and returned as a Board Member in 2011. Thank you to Dana for agreeing to serve as President-Elect again.

I would also like to thank Kim Melgarejo (Treasurer), Ciji Marckini (Technician), and Kristina Rak (Board Member) who all agreed to continue in their previous positions and survived the tight election this year.

Our newest board members are Kasey Bucher and Abby Sturm from Saint Mary's Health Care in Grand Rapids and Kari Vavra, PharmD of Ferris State University.

The next monthly meeting will be held on January 12, 2012 at Borgess Medical center in the Lawrence Education Center Auditorium. Michael Mitchutka, PharmD will be presenting "From Heart Failure to Heart Success".

Save the Date! This year's WMSHP Spring Seminar will be held on May 14, 2012 at the Prince Conference Center on the campus of Calvin College in Grand Rapids.