I hope everyone enjoyed the Holiday season with lots of good friends and warm cheer!

A warm ‘welcome back’ to Jeff VanHouten, Jesse Hogue, and Ryan Bickel, who will be serving for an additional two years as board members. I would also like to take this time to introduce two new board members:

Dana Staat is an Assistant Professor of Pharmacy Practice at Ferris State University. Originating from Port Hope, she traveled to West Michigan to obtain her Pharm D from Ferris State University and then completed her pharmacy practice residency program at Spectrum Health. She oversees the internal medicine rotation at Saint Mary’s Health Care and her interests include pharmacokinetics and infectious disease.

Natalie Vazzana is an Assistant Professor of Pharmacy Practice at Ferris State University. Hailing from Homer Glen (suburb of Chicago), IL, she obtained her Pharm D degree at Purdue University and completed a pharmacy practice residency from McKesson Medication Management at Mercy Hospital and Medical Center in Chicago, Illinois. Her clinical site is Spectrum Health – Butterworth’s internal medicine program. Natalie will be serving for one year, as a replacement for Mitzi McGinnis who will be your new President-Elect.

On behalf of the WMSHP board, I would like to thank Peggy DeVoest, who has done a tremendous job as President in 2004. Also, thanks to Mike Jonkman for his two-year service as Board Member and Jaci DeYoung for her service during her Past-President year. Thank you so much for all your hard work!

I hope to see all of you in the months ahead for the great educational programs we have planned. Please feel free to contact any member of the board or myself with ideas you may have for educational programs, topics you would like to have addressed, or ideas for our website. Please check out our website at www.wmshp.net.

On October 18th, WMSHP co-sponsored a residency showcase with Ferris State University in Grand Rapids at MERC. There were about forty people in attendance, which included program directors, residents and P2-P4 pharmacy students. The program was set up so that the each of the eleven programs from around the state could provide a brief overview of their pharmacy practice residencies and specialty residencies. Following the presentations, each of the programs’ representatives was available so the students could ask additional questions. Overall, the program was very valuable for both students and residency directors.

An upcoming event to consider is the MSHP annual meeting on November 12 at the Lansing Center in downtown Lansing. The program agenda and registration can be obtained at www.michiganpharmacists.org.

It is well-known that all licensed pharmacists must complete thirty hours of continuing education every two years for renewal. These hours can consist of any of the following forms of education: on-line, journals or live programming. Currently, pharmacists can elect to earn all their credits in one venue and may never attend a single program; but, this may all change in the future. The Board of Pharmacy has proposed that at least ten of the thirty hours be obtained from live programs. This proposal is being considered, and if passed, may go into effect starting next year. The WMSHP Board is considering this proposal very carefully and working hard to ensure that most if not all of our programs will offer continuing education for all of its members. We want to offer programs that are informative and useful for daily practice. Please let me know what you would like to see in the programming.

Another opportunity to obtain live continuing education is the Michigan Society of Health-System Pharmacists annual meeting. This year, the conference will take place on November 12th at the Lansing Center from 9:00-4:30. The program includes a wide variety of topics for pharmacists, technicians and students. The opening session includes two presentations: one on Bioethics, followed by a discussion on Emergency Preparedness. The afternoon offers three concurrent sessions focusing on leadership, pharmacy technicians and a clinical session. Some topics of note include pharmacogenomics, pharmacoeconomics, pharmacy informatics and technology. For more information log on to the MPA website at www.michiganpharmacists.org.

We are now accepting nominations for the following positions:

• Board Members – 2005 through 2006
   
• President-Elect – 2005

Please email the names of potential candidates to us at nominations@wmshp.net. Our membership will have the opportunity to vote on candidates when the October newsletter is distributed.

Labor Day marks the last celebration of summer. This Holiday is also very unique since it doesn’t glorify a conflict, battle, person, race or nation. It is celebrated the first Monday of September and is devoted to the achievements of all American workers. Labor Day for me symbolizes the beginning of Fall. Usually at this time I stop to regroup and reflect on the events that occurred over the Summer and plan the upcoming Fall.

During the Summer, the Board had a meeting to plan the education programs for the upcoming months. As in years past, we are having monthly meetings starting in September and rounding out the year in May with the Annual Spring Seminar. December is the only month we will not conduct an education session. The programs will be rotating between Grand Rapids and Kalamazoo monthly. We are attempting to schedule meetings on the second Thursday of the month based on speaker and facility availability. We are also beginning to organize the Spring Seminar for May 2005. If you have topics you would like presented at either monthly education meetings or Spring Seminar please forward those to me at devoestm@ferris.edu. Also, remember to check out the WMSHP website (www.wmshp.net) for program details. It is loaded with useful information including information on our monthly CE programs, resources for PDA’s, and much more. I look forward to hearing from you!

This month our education program is slightly different than most programs. Two pharmacy practice residents will present their residency projects that they have been working on during the year. This year Dana Staat from Spectrum Health in Grand Rapids and Michelle Brodin from Mercy Health System in Muskegon have been selected.

Dana completed her pre-Pharmacy education and Pharm.D. degree through Ferris State University. Dana’s project is entitled "The Development and Implementation of a Pharmacy Competency Program". This was formed around the premise that health care is a rapidly changing field that requires constant education and a commitment to learn. Competencies are one way to accomplish continual education and training. To begin this continual process at Spectrum Health, a survey was administered to pharmacists to gauge the interests and needs that each individual pharmacist required for optimal education. After the results of the survey were tabulated, it was clear that a combination of CE and a shared-drive-based packet would serve best as a competency tool. Community-acquired pneumonia was chosen as the pilot focus for the competency template. After the competency was given, a follow-up survey was distributed to the same pharmacists to gain further information on the effectiveness of this education process. Documentation of pharmacist competency was also created as part of the formation of the competency program. Results of the effectiveness of the competency template will be reported at the April WMSHP meeting.

Michelle received her Pharm.D. from South Dakota State University College of Pharmacy in May of 2003. Michelle’s project involves anemia management in renal failure. She is working with area nephrologists to develop and improve a pre-dialysis monitoring service for outpatient kidney disease patients who are on either Procrit or Aranesp. She will describe their current practice and outline future plans for the service. Included in her evaluation of the project will be dosing of the medications, hemoglobin goals, hemoglobin monitoring frequency, iron lab frequency, management of missed doses, and a cost assessment. Since it is in the early stages, it is difficult to draw many conclusions on the success of the program, however preliminary data look promising.

Ironically, some of the most serious consequences of hypernatremia can result not from the condition itself but from the inappropriate management of the condition. The intravenous infusion of profoundly hypotonic solutions can lead to hemolysis and other severe consequences.

Jennifer Hagerman, Pharmacy Practice Resident at Borgess Medical Center, writes of the dangers of sterile water in the April WMSHP Newsletter.

____

Even Water Can Be Dangerous

Jennifer Hagerman, Pharm.D.

____

Hypernatremia, defined as a serum sodium concentration greater than 145 mEq/L, is a serious electrolyte disorder and is associated with significant mortality in the hospitalized patient. Ironically, some of the most serious consequences of hypernatremia can result not from the condition itself but from the inappropriate management of the condition. The Institute for Safe Medication Practices (ISMP) has recently published several reports of medication errors involving the inappropriate management of hypernatremia. Most of the reports involved physicians who wrote for “plain water” or “free water” to be administered intravenously. Free water does not contain any additives to normalize tonicity and as a result has an osmolality of 0 mOsm/L.

In the body, normal serum osmolality is tightly regulated between 275 – 290 mOsm/L. The intravenous infusion of profoundly hypotonic solutions can lead to hemolysis and other severe consequences. Although sterile water can be administered orally for the treatment of hypernatremia, it should never be administered intravenously without additives to normalize tonicity.

In one case cited by ISMP, an elderly patient was admitted to the intensive care unit (ICU) with severe hypernatremia. The patient also presented with congestive heart failure, pneumonia, respiratory failure and hyperglycemia. The physician decided that the rising serum sodium precluded the further use of sodium solutions and that the presence of hyperglycemia made the use of dextrose solutions undesirable. These circumstances lead to the physician’s ill-fated decision to order “free water” to be administered through a peripheral IV at 100 mL/hr. In response to the physician’s order, a pharmacy intern sent a two-liter bag of sterile water for injection up to the patient’s floor. The bag was then hung by the patient’s nurse despite the warning label stating “Not for Direct Infusion”. The patient received a total of 550 mL of sterile water intravenously before the warning was noticed and the infusion was discontinued. As a result of the profoundly hypotonic infusion the patient experienced a hemolytic reaction, acute renal failure, and ultimately died. This case illustrates that even water can be dangerous when given inappropriately.

As a result of this case and reports of similar cases, ISMP has made several recommendations to help prevent the intravenous administration of sterile water from occurring at other institutions. It is important that practitioners have an understanding of the physiology behind infusing hypotonic, isotonic and hypertonic solutions in response to a patient’s electrolyte concentrations.

The treatment of hypernatremia can be especially difficult in patients with co-mordid conditions that appear to limit therapeutic options. Guidelines should be established to aid in the treatment of hypernatremia in these complicated situations. It is important that practitioners recognize that the appropriate treatment of hypernatremia generally consists of infusions that contain some sodium. It is crucial that hypernatremia is corrected slowly in order to prevent cerebral edema from occurring. Any order that is received for the intravenous administration of sterile water should prompt an immediate call to the physician. In addition, ISMP urges that all large-volume parenteral bags of sterile water are stored in the pharmacy and are not available up on the floors.

Please help educate fellow practitioners about the appropriate treatment of hypernatremia and the inherent dangers of infusing sterile water intravenously.

References

1. Even more about sterile water. ISMP Medication Safety Alert! 2003;8(6):3.
2. How sterile water bags show up on nursing units. ISMP Medication Safety Alert! 2003;8(19):1-2.
3. Water, water everywhere but please don’t give IV. ISMP Medication Safety Alert! 2003;8(2):1-2.

Whether March is in like a lion and out like a lamb, or in like a lamb and out like a lion, Spring is just around the corner, which means WMSHP 35th Annual Spring Seminar. This year, past-president Jaci DeYoung is feverishly working to confirm speakers for the seminar. The seminar this year is May 6th at the Hilton Grand Rapids Airport. It will include a general session with a presentation on Emergency Medicine, and a review of the new community acquired pneumonia guidelines. The afternoon will offer three tracks to select from with three presentations within each. The tracks are categorized into technician, critical care and ambulatory care. The technician track will include presentations on vaccines, law review and math review. Ambulatory care track will include discussions on Alzheimer’s disease, cardiovascular and anticoagulation updates. The final track, critical care, will include presentations on proton pump inhibitors, prevention of venous thromboembolism and nutrition support in the critically ill. So mark your calendars for May 6th. I hope to see you there

NSAIDs have gained popularity as a pediatric treatment for pain and fever. However, these drugs may still be associated with some important risks. In the March WMSHP newsletter, Renee Marana, Pharm.D., a Pharmacy Practice Resident at Bronson Methodist Hospital, writes of the use of NSAIDs in neonatal patients.

___________

NSAIDs in Neonates: Are They Safe?

Renee Marana, Pharm.D.

___________

Pain and fever are common symptoms in neonates for which effective treatments are necessary.¹ Neonates may experience pain after procedures or related to underlying conditions. Acetaminophen is often used first line to treat pain and fever, although physicians, nurses, and families often find the need for additional analgesics and/or antipyretics. This is usually when nonsteroidal agents are considered.

The use of nonsteroidal anti-inflammatory drugs (NSAIDs) has become routine for adults and children in the management of pain, and NSAIDs have gained popularity for the treatment of fever secondary to the association of Reye syndrome with aspirin.¹ NSAIDs are also commonly used in neonates for closure of patent ductus arteriosus. Although generally considered relatively safe agents, NSAIDs are not without their risks, especially when used during the neonatal period. Overall, there is a lack of data concerning the use of NSAIDs in the neonatal population for purposes other than closure of the ductus arteriosus.

NSAIDs inhibit the cyclooxygenase enzyme, which leads to decreased synthesis of prostaglandins. Prostaglandins are important for the healthy development of neonates. They are involved in the development of numerous organ and physiologic systems such as the sleep cycle, cerebral blood flow, renal hemodynamics, thermoregulation, hemostasis, and the pulmonary, central nervous, and cardiovascular systems.¹ There is evidence that the proper genesis of these systems may be adversely affected by NSAID exposure in utero and during the neonatal period.¹

Therefore, interfering with prostaglandin synthesis with the use of NSAIDs may expose the newborn child to unique developmental risks. There have been numerous reports of nephrotoxicity in neonates that were exposed to NSAIDs at an early age.³ Although indomethacin appears to have the most effect on renal blood flow, other NSAIDs, such as ibuprofen, are also associated with decreased renal function.⁴ When assessing the increased risk for bleeding, ketorolac has been associated with the most pronounced effect, although other NSAIDs also increase the risk of bleeding.²

The NSAIDs are also associated with adverse effects on the gastrointestinal (GI) system, such as abdominal pain and ulceration. In response to adverse GI effects came the development of the cyclooxyenase-2 (COX-2) inhibitors. Although they are relatively safe to use in adults, safety and efficacy have not been evaluated in neonates. The COX-2 enzyme is also involved in the development of many organ systems, and its inhibition may lead to a prothrombotic state.¹

NSAIDs should be used cautiously in infants with underlying hepatic dysfunction, impaired renal function, hypovolemia or hypotension, coagulation disorders, thrombocytopenia, or active bleeding from any cause.^2,3 It is important to be aware of the possible adverse reactions caused by NSAIDs so that proper monitoring can be performed and the agent can be discontinued, if needed.²

When the need for an analgesic or antipyretic arises in the neonatal population, many factors must be considered before choosing a non-steroidal agent. Intermittent doses of a non-steroidal may at times be needed and appropriate, although regular scheduled use of these agents is usually not indicated. It has been stated that NSAIDs should be used with extreme caution in infants. Other agents, such as acetaminophen, and narcotic agents should be used preferentially for fever and pain. Neonates that do receive NSAIDs should be monitored closely for adverse effects on the kidneys, platelets, hemostasis, and other organ systems.

References:

1. Morris JL, Rosen DA, Rosen KR. Nonsteroidal anti-inflammatory agents in neonates. Paediatr Drugs 2003;5:385-405.
2. Kokki H. Nonsteroidal anti-inflammatory drugs for postoperative pain: a focus on children. Paediatr Drugs 2003;5:103-23.
3. Cuzzolin L, Dal Cere M, Fanos V. NSAID-induced nephrotoxicity from the fetus to the child. Drug Saf 2001;24:9-18.
4. Pezzati M, Vangi V, Biagiotti R, et al. Effects of indomethacin and ibuprofen on mesenteric and renal blood flow in preterm infants with patent ductus arteriosus. J Pediatr 1999;135:733-8.

February is the Michigan Pharmacy Association (MPA) Annual Convention and Exposition (ACE) in Dearborn. This year’s theme is Pathways to Positive Outcomes. The conference offers programs for pharmacists, technicians and students.

As is previous years, WMSHP will be participating in the MPA Leadership Breakfast scheduled Saturday morning during the ACE. The breakfast meeting theme will revolve around membership retention and recruitment. The WMSHP members that will be representing you are Jeff Van Houten, Jesse Hogue and Vicki Sternhagen. Also, there is the MPA house of delegates session at the ACE. WMSHP this year is entitled to four delegates. Your 2004 delegates are Jeff Van Houten, Jesse Hogue, Brad Miller and Jean Lee. The alternative delegate is Vicki Sternhagen. The delegates will identify issues and policies to be considered by the Executive Board, and consider bylaw changes. Please contact any of the above representatives with topics or ideas that you would like discussed at their meetings.

New this year at the MPA ACE meeting is a session that will be conducted by pharmacy students. Each College of Pharmacy will have one student presenting. The student representing Ferris State University is Sheila Duffy. Her presentation is entitled “The Use of Alternative Medicines in Type 2 Diabetic Patients: Panacea, Placebo or Poison?”. Specifically, Sheila will be discussing the affects of chromium and ginseng in type 2 diabetes and providing recommendations for their use in therapy.

I hope to see some of you at the MPA ACE meeting Dearborn and the WMSHP meeting in Kalamazoo this month.