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December 2017 Newsletter
A wall calendar with tear-away pages and words that read Save the Date
VSHP Meetings in 2018

Spring meeting
April 12-14, 2018
Marriott Short Pump
Richmond, VA

Fall Meeting
November 1-3, 2018
Kingsmill Resort
Williamsburg, VA
VSHP Award recipients 2017
Pharmacist of the Year-Lindsay Enzor

I am pleased to be able to present this year's award for VSHP Pharmacist of the Year.  This year's winner has been associated with pharmacy, and with the same healthcare system, for almost her entire life and I have been aware of this person's professional career for much of that time.  This year's winner has been volunteering in the pharmacy area since
 high school.  At age 18, she obtained PTCB certification and became a paid pharmacy technician.  She earned a PharmD from Virginia Commonwealth University and went on to complete a PGY-1 residency the following year within this same healthcare system.  This person obtained board certification in pharmacotherapy and became a clinical pharmacist and practiced at two different hospitals within that system.  She ultimately became a clinical pharmacy manager within the system.  Shortly thereafter, this year's winner was named the Director of Pharmacy at Riverside Doctor's Hospital in Williamsburg.  After a little over a year in that position she was chosen to become the new Director of Pharmacy for the system's largest hospital, Riverside Regional Medical Center.  During this time, while running the pharmacy department for a major medical center, this person completed the requirements for obtaining an MBA degree in Healthcare Administration from St Leo's University.  This person was also recently selected by ASHP to participate in the Boston University School of Management Pharmacy Leadership Program.

This year's winner has been involved with VSHP since early in her career. She has performed as President and President-elect several times for VSHP Region 5 and has been very active in attending the educational programs sponsored by VSHP.  This person serves as a preceptor for both Hampton University School of Pharmacy and VCU School of Pharmacy.  Finally, for the last four years, our winner has held the chairpersonship of the Pharmacy Committee for Peninsula EMS for.  She was recently recognized for this dedication and hard work in support of the EMS community in Hampton Roads. 
For all of these accomplishments and, I'm sure, many more to come, it is my great pleasure and privilege to present the 2017 Pharmacist of the Year Award to Lindsay Enzor.
R. D. Anderson Award-Rafael Saenz

Rafael Saenz is an influential leader in health  system pharmacy in Virginia.   After completing his Pharm Ddegree at VCU, Rafael completed aPGY2 pharmacy administration residency at University of
  Wisconsin. After spending time at the University of Pittsburgh Hospitals in Pharmacy leadership, Rafael accepted a position  as  Director of Inpatient Pharmacy at the University  of Virginia.   He subsequently was promoted to  lead the department.  During his time at the University of Virginia, Rafael has accomplished many things at the organization, state and national level, including:  
  1.  Serving as President for VSHP
  2.  Initiating the VSHP Commonwealth Leadership Forum
  3. Developing an ASHP accredited technician training program in collaboration with Piedmont Virginia Community College, which may become a model for the Virginia Community College system
  4. Served on numerous ASHP committees. Is currently serving on the ASHP Pharmacy Technician Task Force
  5. Serves on the Virginia Board of Pharmacy
  6. Enhanced the residency programs offered by UVa, including the PGY2 pharmacy administration residency.
  7. PGY1 residency program recognized by the ASHP Foundation:Residency expansion grant (2015), Residency Program Excellence Award (2017)
  8. Serves as a remote site for the VCU school of pharmacy
New Practitioner Award-Rachel Flurie

Rachel Flurie, the recipient of the New Practitioner award for 2017, has been at the VCU School of Pharmacy since 2014 and has contributed to VSHP by organizing clinical articles for the newsletters, working with the Education Committee, and helping to facilitate the Clinical Skills competition. She is also a skilled clinician in Internal Medicine, and a committed educator of pharmacy students.




Pharmacy Technician of the Year-Coley Deal

Coley obtained his  pharmacy technician training at the J Sargent Reynols program in Richmond.  Coley worked as a certified pharmacy technician at Bon Secours Richmond through undergraduate studies at  Randolph Macon College.   Shortly  after graduating from Randolph Macon, Coley took on the role of 340B analyst for Bon Secours Richmond Memorial and Bon Secours Maryview
Hospital.   Most recently, Coley has been promoted to oversee all 340B sites within Bon Secours,and has analysts working for him.
 
Since the beginning of his work in 340B, Coley has represented Bon Secours at both the state and national level through legislative visits and advocacy work with Medicaid.Coley was very  involved with the Virginia 340B community as they worked to educate Medicaid leadership on  the important role that 340B plays in health systems, federally qualified health clinics, and Ryan White grantees.  Coley is now taking the leadership role in the  effort to find opportunities  between 340B organizations and the  state Medicaid agency. Coley also organized a 340B round table in Virginia in June 2017.
 
Coley is an excellent example of pharmacy technicians taking expanded roles in health system pharmacy.
VSHP Clinical Skills Competition


Congratulations to Alyssa Hager and Kyle Sandridge from VCU for winning the VSHP Clinical Skills Competition 2017. 


Do you need the Controlled Substance required CE?

If so, we invite you to participate in our online video entitled "Examining Opioid Overdose and Inpatient Detox: https://vimeo.com/214567203

There is no charge for members.  Non-member fee is $20.

Pharmacy Credit
Virginia Society of Health-System Pharmacists is accredited by the Accreditation Council for Pha rm acy Education (ACPE) as a provider of continuing pharmacy education.  This program is approved for 1 hour (0.1 CEU) of continuing pharmacy education credit.  Proof of participation will be posted to your NABP CPE profile within 4 to 6 weeks to participants who have successfully completed the activity.   Participants must participate in the entire presentation and complete the course evaluation to receive continuing pharmacy education credit.

ASHP Pharmacy Technician Forum 
Executive Committee Nominations

ASHP recently launched the Pharmacy Technician Forum and is currently seeking recommendations for technicians to serve on the inaugural Pharmacy Technician Forum Executive Committee for the 2018-2019 term.

The Executive Committee will be comprised of five pharmacy technicians who will advise ASHP on the optimal benefits and services, education, tools, professional practice policies, and resources technicians need to enhance and advance their careers and to further elevate their vital roles as members of the interprofessional patient care team.

The deadline for recommendations is February 5, 2018.

ASHP is especially interested in appointing pharmacy technicians to this inaugural committee who reflect a diverse pool of knowledge, practice expertise, and have a strong interest to represent pharmacy technician workforce needs and abilities on a national level.

Individuals must complete the online Submission Form to recommend themselves or someone else for appointment. Individuals may also make more than one recommendation. If you have any questions, please contact Tyffani Wingfield in the Office of Member Relations at membership@ashp.org.

For more information about the Pharmacy Technician Forum, please visit ashp.org/technicians
Clinical Article

Anticoagulation Bridging in Atrial Fibrillation: To Bridge or Not to Bridge?
Rashmi Patel, PharmD, BCPS, VCU Health System and Rachel W. Flurie, PharmD, BCPS, VCU School of Pharmacy

Atrial fibrillation (AF) is the most common type of cardiac arrhythmia and is an independent risk factor for the development of ischemic stroke.1  Anticoagulation with warfarin can decrease the relative risk of a stroke associated with AF by up to 47-86% with an annual bleeding risk of 2-4% when the international normalized ratio (INR) is maintained within a therapeutic range of 2-3.2  Warfarin works as a vitamin K antagonist that reduces the coagulant activity of blood by reducing the production of vitamin K-dependent factors.  Due to an initial prothrombotic state (from decreasing protein C and S) and a delayed onset of action, warfarin is commonly "bridged" with a short-acting blood thinner (usually heparin) until its full anticoagulant effect is achieved.  The focus of this article will be to provide insight into bridge therapy for AF patients on warfarin when the anticoagulant is interrupted for procedures.  This misconception of bridging warfarin for patients with AF is often confused with the standard practice used to treat an acute deep vein thrombosis or pulmonary embolism.  The requirement to bridge warfarin for patients with a venous thromboembolism (VTE) is based on a randomized, double-blind study from 1992 that compared heparin bridging versus no bridging among patients receiving warfarin for DVT.3  At the end of the first week, the patients without a heparin bridge were more likely to have an extension of their DVT or a new PE versus those with a bridge (39.6% vs 8.2%, p<0.001), and as a result the study was prematurely discontinued.3  While the decision to bridge in VTE depends on the time out from the acute event, the necessity to anticoagulate for patients with AF is based on the CHA2DS2-VASc score.

Among patients with AF with an elevated CHA2DS2-VASc score, it seems beneficial to bridge until the INR is at goal. However, not only is this practice unnecessary, it may actually be harmful to patients.  The 2014 AHA/ACC/HRS guidelines recommend that patients with AF be anticoagulated with either warfarin (class IA) or a direct oral anticoagulant (class IB) among patients with a CHA2DS2-VASc score of 2 or more.4  The CHA2DS2-VASc score estimates the risk of a stroke or thrombotic embolism per year in patients with AF and can range from 0% to 15.2%.5  If this total risk over a year was extrapolated to a 5-day period, which is the typical discontinuation duration before surgery, the stroke risk is very low (0.03% to 0.2%).  Given the small risk of stroke during a 5-day period, the requirement of bridging to warfarin in patients with AF becomes debatable.

The 2014 AF guidelines recommend bridging to warfarin for patients with mechanical valves, but provide little guidance on how to manage temporary or planned interruptions in warfarin therapy.4  The BRIDGE trial was designed to answer this specific question: in patients with AF, is heparin bridging necessary during interruption of warfarin therapy before and after an operation or other invasive procedure?6  The randomized, double-blind, placebo-controlled non-inferiority study included 1,884 patients who were undergoing an elective procedure with planned warfarin interruption.  Patients were then randomized to receive anticoagulation bridging with low molecular-weight heparin, dalteparin, or placebo three days prior to procedure.  In both groups, warfarin was restarted within 24 hours after the procedure.  The average patient was 72 years old, most likely to be male, Caucasian, 95 kg, with a mean CHADS2 score of 2.3 (majority ranging from 1-4),making the study population largely moderate thromboembolic risk.  The primary endpoints were thromboembolism and major bleeding.  The results of the trial demonstrated there was no difference in thromboembolism between those randomized to the dalteparin bridge versus those without bridge therapy (0.3% vs 0.4%, p=0.01 for non-inferiority) at the 30 days post procedure follow up.  In contrast, bridging conferred a risk of major bleeding that was nearly triple the risk associated with no bridging (3.2% vs 1.3%, p=0.005).  This study demonstrates a lack of benefit with bridging to prevent a thromboembolism, and an increase in the major bleeding risk for patients with AF during warfarin interruption.  Therefore, it appears that bridging in moderate-risk AF populations causes harm without any benefit.

Extrapolation of the BRIDGE results to groups with greater thromboembolic risks, such as patients with AF and a higher CHA2DS2-VASc score, mechanical heart valves, or recent venous or arterial thrombosis, should be done cautiously.  The decision to bridge rests on the balance between thrombosis risk and bleeding risk.  The 2012 CHEST guidelines provide risk-stratified recommendations for perioperative bridging in AF patients. They recommend not bridging patients at a low-risk (CHADS2 score of 0-2) but do recommend bridging patients at high risk of stroke, defined as CHADS2 score of 5 or 6, a recent (within 3 months) history of stroke or TIA, or those with a rheumatic valvular disease. However, there are no graded recommendations for bridging those at moderate risk.7 More recently, the American College of Cardiology published the 2017 Expert Consensus that recommends no bridging for patients at low or moderate stroke risk with no history of ischemic stroke, TIA, or systemic embolism (CHA2DS2-VASc score 0-4 or 5-6, respectively).8 In contrast, if the patient is at moderate stroke risk and has a history of stroke, TIA, or systemic embolism, with no significant bleeding risk, the decision to bridge could be considered. For those at high stroke risk or those who have had a recent (within 3 months) stroke, TIA, or systemic embolism, bridging is recommended unless the patient has a history of major bleeding or intracranial hemorrhage within the last 3 months. Until additional randomized trials give us more definitive results, it is important to carefully consider routine bridging as this treatment is not a benign practice and is associated with a significant bleeding risk.    

  1. Atrial Fibrillation Fact Sheet. CDC. Updated August 22, 2017. Available from:
2. Singer DE, Albers GW, Dalen JE, et al. Antithrombotic therapy in atrial fibrillation: the Seventh ACCP conference on antithrombotic and thrombolytic therapy. Chest . 2004;126:429S-456S.
3. Brandjes D, Heijboer H, Buller HR, et al. Acenocoumarol and heparin compared with acenocoumarol alone in the initial treatment of proximal-vein thrombosis. NEJM . 1992;327:1485-1489.
4. January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. JACC . 2014;64(21):e1-e76.
5. Lip GY, Nieuwlaat R, Pisters R, et al. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the euro heart survey on atrial fibrillation. Chest . 2010;137(2):263-272.
6. Douketis JD, Spyropoulos AC, Kaatz S, et al. Perioperative bridging anticoagulation in patients with atrial fibrillation. NEJM . 2015;373:823-833.
7. Douketis JD, Spyropoulos AC, Spencer FA, et al. Perioperative management of antithrombotic therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest . 2012;141:e326S-e350S.
8. Doherty JU, Gluckman TJ, Hucker WJ, et al. 2017 ACC Expert Consensus Decision Pathway for Periprocedural Management of Anticoagulation in Patients With Nonvalvular Atrial Fibrillation: A Report of the American College of Cardiology Clinical Expert Consensus Document Task Force. J Am Coll Cardiol  . 2017;69(7):871-898.
Clinical Writing Opportunities for APPE Students

As a new year of APPE rotations begin, writing a clinical article for the VSHP newsletter is a great way for students to get publication experience. As preceptors we can co-author these articles with our students, engage them in the writing process, and enhance their rotation experiences. Topics can be anything related to hospital-system pharmacy. Examples include (but are not limited to): new drug updates, national policy updates for hospital pharmacy, guideline updates, therapeutics reviews, and clinical controversies. Articles are generally 1-3 pages in length, and can include tables and figures. Interested member and students should email Rachel Flurie, rwflurie@vcu.edu for more details.

 
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