Obesity and Weight Management

Learning and Earning with Gateway Professional Education CME/CEU Webinar Series

Nicole Kohler, CDE, Clinical Design Specialist, Gateway HealthSM Jennifer Pennock, MD, Center for Diabetes & Endocrine Health, West Penn Hospital Megan Proper, PharmD, Sr. Pharmacist, Gateway HealthSM

Wednesday, October 2, 2019

1 | DATE| PRESENTED BY: DISCLOSURES

Speakers for today’s webinar have no real or potential conflict of interest in relation to this presentation

2 | DATE | PRESENTED BY: To receive CME/CEU credit for today’s webinar

• If you haven’t already, create an account at cme.ahn.org • Text code xxxxxx to xxx-xxx-xxxx • You will receive an email with a link to complete evaluation and claim CE credit • You MUST text by the end of the day today to receive credit! • For pharmacists only: instructions given in Chat box towards end • Questions? Email us at [email protected] Save the dates! Wednesdays 12-1pm: • November 6, 2019 – Cultural Competency • December 4, 2019 – Management of Hepatitis C in the Primary Care Practice Setting

3 | DATE | PRESENTED BY: Enroll today to receive monthly webinar invitations: https://www.surveymonkey.com/r/NZJYDF7

Questions? Email [email protected]

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of Allegheny General Hospital and Gateway Health Plan. Allegheny General Hospital is accredited by the ACCME to provide continuing medical education for physicians. Allegheny General Hospital designates this live webinar activity for a maximum of 1.0 AMA PRA Category 1 CreditTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Allegheny General Hospital is approved by the American Psychological Association to sponsor continuing education for psychologists. Allegheny General Hospital maintains responsibility for this program and its content. Social Workers may claim credits for attending educational courses and programs delivered by pre-approved providers, such as the American Psychological Association.

Allegheny General Hospital Department of Pharmacy Services is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.

4 | DATE | PRESENTED BY: SHOUT OUT!

To arrange for a group viewing and lunch at your practice for a future webinar, please contact your Gateway Clinical Transformation Consultant (CTC).

Suggestions for future topics/speakers? Email your CTC or [email protected] Self nominations welcome!

5 | DATE | PRESENTED BY: Obesity and Weight Management GATEWAY HEALTH’S MEMBERSHIP POPULATION

Gateway has a ~46,000 members classified as overweight or obese • 66% female • 33% male • Average age: 33.7

Concurrent Disease Prevalence • SMI: 30.0% • Hypertension: 26.8% • Asthma: 12.5% • Diabetes: 12.2% • Cardiac: 3.9% • COPD: 2.2%

Many facing Social Determinant of Health factors: living in a food desert, residing in a rural residence, experience socioeconomic inequity and transportation inequity

Health Service Analytics Reporting: PA Medicaid March 2018 - February 2019 GATEWAY HEALTH’S MEMBERSHIP POPULATION

Childhood (ages 2-20) Adult (21+) Enrollment: ~12,000 Enrollment: ~33,000 Females: 50% Females: 72.3% Males: 49.9% Males: 27.6% Average Age: 12.3 Average Age: 41.5

Concurrent Disease Prevalence Concurrent Disease Prevalence • SMI: 11.9% • SMI: 36.6% • Asthma: 10.6% • Hypertension: 26.0% • Hypertension: 1.7% • Diabetes: 16.1% • Diabetes: 1.4% • Asthma: 13.1% • Cardiac: <1% • Cardiac: 5.3% • COPD: 2.9% Health Service Analytics Reporting: PA Medicaid March 2018 - February 2019 OBESITY AND WEIGHT MANAGEMENT

NEW! Healthy Weight Management under Gateway to Lifestyle Management (GTLM) program

Childhood Weight Management Program Gateway to Weight Management Adult Weight Management Program WHAT WE OFFER

Childhood Nutrition and Weight Management Services •For MA beneficiaries under 21 years of age

Credentialing Registered Dietitians •Nutritionists enrolled in the MA Program

Weight Management Texting Program •Enrollees receive 3-5 actionable and inspirational text messages each week

Collaboration with Provider Practices •Developing programs/initiatives tailored to patient needs

Staff Training and Education PROVIDER SUPPORT

Focused on getting services completed and provider education

• Toolkit • Provider Reference Guide and Toolkit

Rate Change from 2016 to 2019 Current Measure (Percentage Points) Percentile ABA 20.2 50th

WCC - BMI 17.18 50th IN DEVELOPMENT

Community Initiatives

Practice Well-Visit Days

In-Home Assessments Obesity and Weight Management Learning 2017and TOWNEarning HALL with Gateway What I Want You to Get From this Talk

1) Understand weight-bias and how to decrease the impact on patients 2) Basic evaluation for patients with obesity 3) Treatment steps for patients with obesity Weight Bias in Healthcare

• 24% nurses stated that they were repulsed by obese people • 31-42% nurses stated they would prefer not to care for those with obesity at all • Healthcare professionals specializing in the treatment of obesity have weight bias • Weight shaming leads to worse outcomes

Obesity Action Coalition . Weight Bias in Healthcare. A Guide for Healthcare Providers, 2014 Schwartz, M et al. Weight Bias Among Professional Specializing in Obesity. Obesity Research Vol 11, No 9 Sept 2003. Decrease Impact of Weight Bias on Patients

• Understanding and compassion for their disease • “People-First Language” – Patient with obesity (instead of obese patient) – Weight-friendly terms • Excess weight • Unhealthy weight • High BMI • Emphasize – Behaviors, not blame – Health, not weight Obesity is an epidemic

Why is the Rate of Obesity Rising?

• Easy access to high calorie foods - • Less physical activity - many sit at desk all day • Ambient temperature • Maternal age • Viral – Adenovirus-36 shown in mice and chickens to cause obesity. – Studies show that people with obesity are more likely to have had this virus than people without obesity. • Endocrine disruptors SW Keith, et al, “Putative contributors to the secular increase in obesity: exploring the roads less traveled.” International Journal of Obesity (2006) 30, • Sleep patterns 1585–1594 Atkinson, Richard. “Obesity Due to a Virus; How This Changes the Game.” Spring 2012 Issue Your Weight Matters Magazine Obesity is a disease

American Medical Association recognized obesity as a disease - 2013

“Recognizing obesity as a disease will help change the way the medical community tackles this complex issue that affects approximately one in three Americans,” Dr. Patrice Harris, AMA member of the board

Twin study Monozygotic Dizygotic Borjeson, Acta Pael Scand 1976

Usually not monogenetic

Specific genetic causes: • Leptin deficiency • MC4R deficiency • Prader Willi Hormones

Stomach – Ghrelin Small intestines – CCK, GLP-1 Large intestines – OXM, PYY Pancreas – Insulin, Amylin Fat - Leptin

Bell et al, Genetics of Human Obesity, Nature Reviews Genetics 2005 Medications that contribute to weight gain . Diabetes medication: . Insulin . Pioglitazone . Sulfonylureas (glipizide, glimepiride and glyburide) . Antipsychotic drugs (Clozapine, Olanzapine, Zotepine) . Antidepressant drugs (amitriptyline, paroxetine and sertraline) . Drugs for epilepsy (valproate, carbamazepine and gabapentin) . Prednisone . Blood pressure medication (beta-blockers) . Implantable Progestins . Anti HIV (HAART) Microbiome

. bacteria, viruses, and fungi occupy almost every surface of the human body . about one bacterium for every cell in the human body . exposed during birth . influenced by environmental factors . Studies in mice and humans – types of bacteria effect weight Mouse studies

Germ free Conventionally donated Conventionally raised Born by C-section Germ free mouse Vaginal birth Sterile environment At 8 weeks old Non-sterile environment 10 cc of fecal contents of conventionally raised mouse spread onto mouse’s fur Sterile autoclaved food Non-sterile food Mouse study results

Germ free mice harvest less energy from food.

. Past trauma . Women who experiences sexual trauma are twice as likely to be obese . Depression and anxiety, daily stresses . self-soothing . Eating disorders . Binge eating disorder . Most common eating disorder . binge eat on average at least once a week . Night eating syndrome – eating most of calories at night Evaluation History

• Weight History – Ask permission to talk about weight – Weight gain – Childhood, puberty, pregnancy, menopause – Job activity change – Prior weight loss efforts & outcomes • Four key contributors to weight – Nutrition – Physical activity – Sleep – Mood • History of diseases that might affect anti-obesity med choice, seizure disorder, glaucoma, pancreatitis, heart valve disease PMH/PSH

Potential causes of Metabolic Other complications of weight change complications weight • Thyroid disease • Prediabetes • Cholecystectomy • Sleep Apnea • Diabetes • Asthma • Depression • Gestational diabetes • Heart Failure • Eating disorder • ASCVD • Urinary stress • Cushing features • Metabolic syndrome incontinence • Meds • NAFLD/NASH • Osteoarthritis • Bariatric surgery • PCOS • Gout • Dyslipidemia • GERD • Hypogonadism • Cancer • Infertility • Depression Physical exam - cause or effect of obesity

– Oropharyngeal opening – Acanthosis Nigricans – Skin tags – Cushingoid appearance – Enlarged liver – Waist circumference • 40 inches (men) • 35 inches (women) – Neck circumference • 17 inches (men) • 16 inches (women) Testing

• CMP (glucose, LFTs, cr) • Lipids • A1c BMI risk of OSA 25 to 28 25% • TSH 28 to 35 40%? • Pregnancy 35 to 39.9 71% • Optional EKG 40 to 49.9 74% • Sleep study 50 to 59.9 77% > or= 60 95% Assessment of Obesity

Body mass index (BMI) in kilograms per meters squared (kg/m2)

Normal Weight Overweight Class I Obesity Class II Obesity Class III Obesity 18.5-24.9* 25.0-29.9 30.0-34.9 35.0-39.9 > 40

AACE/ACE Algorithm for the medical care of patients with obesity

Stage 0 Normal Weight Stage 1 Stage 2 BMI > or = 25 Less than 25* BMI > or = 25 BMI > or = 25 No complications Mild complication Severe complication

* Normal weight BMI less than 23 in certain ethnicities

. Sleep apnea - may not have many symptoms . Endocrine issue . Cushings . Hypothyroidism . Eating disorder . Night eating syndrome – changes in eating pattern, sertraline (not FDA approved use) . Binge eating disorder – CBT, Lisdexamfetamine . Change medications? Treatment of Adult Patients with Overweight or Obesity Medical Management and Coordination

Nutrition Physical Activity Behavior Therapy Pharmacotherapy Bariatric Surgery

5-10% is enough weight loss to improve most weight related medical issues (more in NASH)

Patients do not need a normal BMI

Patients may have a goal in mind Seven evidenced based categories of eating plans

1) Low fat 2) Low carbohydrate 3) Mediterranean Diet 4) Daily calorie restricted meal plan 5) Intermittent calorie restricted meal plan 6) Meal replacement plan 7) Very low calorie diet

Jenpennockmd.com – free video for patients to choose plan Many plans get to the same goal

Shai, Iris, et al. “Weight Loss with a Low- Carbohydrate, Mediterranean, or Low-Fat Diet.” New England Journal of Medicine, vol. 359, no. 3, 2008, pp. 229–241. Physical activity

. National weight control registry . 98% of people modified their diet in some way . 90% of people get at least an hour a day of physical activity . Faster to decrease food than to get physical activity . McDonalds meal of burger, medium fries and small Coke – 730 calories . Running at a 12 minute mile pace 3 days a week for 30 minutes – 730 calories . Physical activity versus exercise . If measuring physical activity – 10,000 steps a day . If adding exercise . Start small, build habit . Long term goal - 30 minutes 5 days a week of moderate exercise (equivalent of brisk walk) Anti-Obesity Medication Principles

• Treatment of a chronic disease • FDA-approved Anti-obesity Medication for use long term • BMI > 30kg/m2 • BMI > 27kg/m2) with medical issue related to weight (e.g., type 2 diabetes mellitus, hypertension, dyslipidemia) • Try one that isn’t contraindicated • If side effects try another • If less than 5% weight loss at 12 weeks, try another

Managing Obesity in Primary Care Practice: An Overview and Perspective from the POWER-UP Study, Int J Obes (Lond). 2013 Aug; 37(0 1): S3–11. ORLISTAT (Xenical™, Alli™*)

*OTC Orlistat (Xenical™, Alli™)

• How does it work? – Lipase inhibitor (inhibits absorption of dietary fats)

Xenical [package insert]. Genentech, Inc: South San Francisco, CA; August 2015. Arq Bras Endocrinol Metab.2009;53(2) Orlistat (Xenical™, Alli™)

• Dosing – Xenical: 120mg PO TID (before meals*) – Alli: 60mg PO TID (before meals*)

*Eating >30% kcal from fat results in greater GI side effects

Xenical [package insert]. Genentech, Inc: South San Francisco, CA; August 2015. Orlistat (Xenical™, Alli™) • Common side effects are GI related – Steatorrhea – Fecal urgency – Incontinence – Flatulence – Oily spotting – Frequent bowel movements – Abdominal pain – Headache

Xenical [package insert]. Genentech, Inc: South San Francisco, CA; August 2015. Orlistat (Xenical™, Alli™)

Contraindications Cautions

Chronic malabsorption syndrome Rare liver injury

Cholestasis Malabsorption of fat-soluble vitamins

Oxalate nephrolithiasis Drug interactions

Xenical [package insert]. Genentech, Inc: South San Francisco, CA; August 2015. LORCASERIN (Belviq™) Lorcaserin (Belviq™)

• How does it work? – Serotonin (5HT2c) receptor agonist

J Clin Med Res. 2009;1(2):72-80. Pharmacol Rev.1994;46(2):157-203. Lorcaserin (Belviq™)

• Dosing – ER: 20mg PO QD – IR: 10mg PO BID

BELVIQ®/BELVIQ XR® [package insert]. Woodcliff Lake, NJ: Eisai Inc; 2016. Lorcaserin (Belviq™) • Common side effects – Headache – Nausea – Dizziness – Fatigue – Xerostomia – Constipation – Diarrhea – Hyperprolactinemia

BELVIQ®/BELVIQ XR® [package insert]. Woodcliff Lake, NJ: Eisai Inc; 2016. Lorcaserin (Belviq™) Contraindications Cautions Cautions cont.

Serotonin syndrome or neuroleptic History of depression Severe liver or kidney disease malignant syndrome

Concomitant use of SSRI, SNRI, MOAI, Bradycardia, heart block, or heart failure Wellbutrin, St. Johns Wort

Uncontrolled mood disorder Leukopenia

Cognitive impairment Priapism

BELVIQ®/BELVIQ XR® [package insert]. Woodcliff Lake, NJ: Eisai Inc; 2016. PHENTERMINE/ TOPIRAMATE ER (Qsymia™) Phentermine/Topiramate ER (Qsymia™)

• How does it work?

•NE-releasing agent Phentermine •Works quickly to reduce appetite

•GABA receptor modulation Topiramate •Works throughout the day •Provides feeling of fullness ER •Alters the taste of certain foods, helping to reduce the pleasure of eating

Qsymia [package insert]. Campbell, CA : Vivus, Inc;2012 Phentermine/Topiramate ER (Qsymia™)

• Dosing

Starting Dose Recommended Escalation Dose Maximum Dose Dose

• 3.75/23mg PO • 7.5/46mg PO • 11.25/69mg • 15/92mg PO QD x 2 weeks QD PO QD QD*

*Should NOT be discontinued abruptly (increased risk of seizure). Taper over at least one week

Qsymia [package insert]. Campbell, CA : Vivus, Inc;2012 Phentermine/Topiramate ER (Qsymia™) • Teratogenic • Monthly pregnancy test • Only use if on adequate birth control • Common side effects – Paresthesia – Insomnia – Xerostomia – Increased heart rate – Anxiety – Cognitive impairment (concentration and memory) – Dysgeusia (metallic taste)

Qsymia [package insert]. Campbell, CA : Vivus, Inc;2012 Phentermine/Topiramate ER (Qsymia™)

Contraindications Cautions Cautions cont.

Hyperthyroidism Tachyarrhythmias Hyperchloremic metabolic acidosis

Renal/hepatic impairment dose Acute angle-closure glaucoma Decreased cognition adjustments

Concomitant MAOI use (within 14 days) Seizure disorder Concern for abuse

Anxiety and panic attacks Use with alcohol or depressant drugs

Nephrolithiasis

Qsymia [package insert]. Campbell, CA : Vivus, Inc;2012 Phentermine/Topiramate ER (Qsymia™) • Clinical Pearls – Potential for lactic acidosis in combination with metformin – Can cause menstrual spotting in women taking birth control due to altered metabolism of estrogen and progestins

Qsymia [package insert]. Campbell, CA : Vivus, Inc;2012 NALTREXONE ER/ BUPROPION ER (Contrave™) Naltrexone ER/ Bupropion ER (Contrave™)

• How does it work?

Naltrexone • Opioid ER antagonist

• Reuptake Bupropion ER inhibitor of NE and DA

Contrave [package insert]. Orexigen, La Jolla, CA. May 2017 Naltrexone ER/ Bupropion ER (Contrave™) • Dosing – 1 tab (8/90mg)

Week Week Week Week 1 AM 2 AM 3 AM 4 AM • 1 tablet • 1 tablet • 2 tablets • 2 tablets

PM PM PM • 1 tablet • 1 tablet • 2 tablets

Contrave [package insert]. Orexigen, La Jolla, CA. May 2017 Naltrexone ER/ Bupropion ER (Contrave™) • Common side effects – Nausea – Headache – Insomnia – Constipation – Dizziness – Anxiety – Xerostomia

Contrave [package insert]. Orexigen, La Jolla, CA. May 2017 Naltrexone ER/ Bupropion ER (Contrave™) Contraindications Cautions

Uncontrolled hypertension Cardiac arrhythmia

Seizure disorder Renal/hepatic impairment dose adjustments

Anorexia or Bulimia Narrow-angle gluacoma

Severe depression Uncontrolled migraines

Drug or alcohol withdrawal Generalized anxiety disorder

Concomitant MAOI (within 14 days) Bipolar disorder

Chronic opioid use Depression

Contrave [package insert]. Orexigen, La Jolla, CA. May 2017 LIRAGLUTIDE 3MG (Saxenda™) Liraglutide (Saxenda™)

• How does it work? – GLP-1 Receptor Agonist

Saxenda® [package insert]. Plainsboro, NJ: Novo Nordisk Inc; 2017. Liraglutide (Saxenda™)

• Dosing • 0.6mg SC QD – Titrate dose • 1.2mg SQ QD weekly by 0.6mg as tolerated by • 1.8mg SQ QD patient • 2.4mg SQ QD • 3.0mg SQ QD

Saxenda® [package insert]. Plainsboro, NJ: Novo Nordisk Inc; 2017. Liraglutide (Saxenda™) • Common side effects – Nausea – Vomiting – Diarrhea – Headache – Dyspepsia – Increased heart rate Saxenda® [package insert]. Plainsboro, NJ: Novo Nordisk Inc; 2017. Liraglutide (Saxenda™) Contraindications Cautions

Personal or family history of medullary Gastroparesis thyroid cancer or MEN2

Several renal impairment from Pancreatitis vomiting/dehydration

Acute gallbladder disease Cholelithiasis

Injection site reactions

Saxenda® [package insert]. Plainsboro, NJ: Novo Nordisk Inc; 2017. Liraglutide (Saxenda™) • Monitoring – Pancreatitis – Cholelithiasis – Increased heart rate – Dehydration from nausea/vomiting – Injection site reactions

Saxenda® [package insert]. Plainsboro, NJ: Novo Nordisk Inc; 2017. Special Populations

• Pregnancy/Breastfeeding – All are contraindicated – Counsel on contraception use during therapy • Age ≥65yo – Limited data available • Patients with T2DM – Hypoglycemia risk, especially if treated with insulin and/or sulfonylurea Bariatric surgery . Indication . BMI greater than 40 . BMI greater than 35 with diabetes or other major health issue . More significant weight loss with surgery than with lifestyle and medications . Two major types of surgeries done . Roux-en-Y – more weight loss, some potential complications . Gastric sleeve Bariatric Surgery

Roux-en-Y Long term outcomes bariatric surgery

L. Sjöström, Review of the key results from the Swedish Obese Subjects (SOS) trial – a prospective controlled intervention study of bariatric surgery, Journal of Internal Medicine, 19 November 2012 https://doi.org/10.1111/joim.12012 Considerations with weight loss . Consider monthly visits . medication adjustments . Thyroid hormone . Diabetes medication . Hypertension meds . People who see provider more keep weight off better . After gastric bypass, maintain vitamins, monitor B12, vit D, iron . Emotional and relationship issues may arise Preventing weight regain . Hormones that regulate appetite and metabolism change with weight loss . Continue to see patient in office . Continue meal plan - maybe a modified version . Continue physical activity – an hour a day is great . Continue anti-obesity medications Summary

• Obesity is a common disease • Decreasing weight bias leads to better outcomes • Screen for diabetes, hyperlipidemia, NAFLD, sleep apnea • Lifestyle change is mainstay of treatment • There are effective FDA approved anti-obesity medications for long term use • Consider bariatric surgery evaluation (if indicated) Pharmacotherapy and Weight Management Pharmacotherapy and Weight Management

Objectives: 1. Discuss safety and efficacy of weight loss medications 2. Describe medications that are FDA approved for weight management 3. Review comorbid conditions and risk factors when considering weight loss medication therapy Pharmacotherapy and Weight Management

• When used as an adjunct to lifestyle changes, medication-assisted weight loss is a viable consideration. • Short and long-term medications are available to assist with weight reduction. Pharmacotherapy and Weight Management

• When prescribed, administered, and monitored correctly medication-assisted weight loss is a safe addition to help achieve weight-loss goals. • Pharmacotherapy is not a stand alone treatment and should not be used as a “quick fix”. Test Your Knowledge Weight loss medications can be used safely and effectively as an adjunct to lifestyle changes

True or False Pharmacotherapy and Weight Management

• There are currently 6 medications with an FDA- approved indication for weight loss. – Phentermine (Adipex)- approval for short term use only – Phentermine/Topirimate (Qsymia) – Naltrexone/Buproprion (Contrave) – Liraglutide (Saxenda) – Lorcaserin (Belviq) – Orlistat (Alli as an OTC product and Xenical) Pharmacotherapy and Weight Management

• Medications used off-label for weight loss – Topirimate (Topamax) – Zonisamide (Zonegran) – Buproprion (Wellbutrin) – Injectable GLP-1 RA: Liraglutide (Victoza), Exenatide (Byetta and Bydureon), semaglutide (Ozempic), dulaglutide (Trulicity) Test Your Knowledge Which medications have an FDA approval for weight loss? A. Buproprion (Wellbutrin) B. Liraglutide (Saxenda) C. Topiramate (Topamax) D. Zonisamide (Zonegran) Pharmacotherapy and Weight Management

• When considering weight loss therapy, comorbid conditions and risk factors should be considered when deciding which medication to choose. • Chronic kidney disease, heart disease and history of arrhythmia, diabetes, seizure disorder, depression, and substance use disorder are major considerations Pharmacotherapy and Weight Management

• In the setting of bariatric surgery, it was demonstrated that the addition of pharmacotherapy halted weight regain, with greater than one-third having more than 5% weight loss. • The response was greater in gastric bypass and banding patients vs. sleeve gastrectomy patients as well as those with a higher BMI. • Given a greater safety profile of medication therapy vs. revisional surgery, medication is a better option. Test Your Knowledge Comorbid conditions and risk factors should always be considered when deciding on weight loss medication. Those conditions and risk factors include: A. Heart disease B. Diabetic retinopathy C. Seizure disorder D. A and C References

1. J Psychosoc Nurs Ment Health Serv. Leahy, L. 2017 Aug 1;55(8):21-26 2. Surg Obes Relat Dis. Nor Hanipah Z, Nasr EC, Bucak E, Schauer PR, Aminian A, Brethauer SA, Cetin D. 2018 Jan;14(1):93-98 To receive CME/CEU credit for today’s webinar

89 | DATE | PRESENTED BY: Enroll today to get CME credit and receive monthly webinar invitations: https://www.surveymonkey.com/r/NZJYDF7

Questions? Email [email protected]

Allegheny General Hospital Department of Pharmacy Services is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.

90 | DATE | PRESENTED BY: PHARMACISTS ONLY

Post-CE Evaluation Link (this link will expire 2 weeks after the program date)

https://www.surveymonkey.com/r/RPhGatewayCPE-ObesityManagement-Oct19

Allegheny General Hospital Department of Pharmacy Services is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. In order to receive 0.1 CEU (1 contact hour of credit), the pharmacist participant must attend the entire activity and complete the on-line program evaluation. ACPE Program # 0547-9999-19- 025-L01-P. Statements of Continuing Pharmacy Education will be distributed via the NABP CPE Monitor to attendees within 60 days of this program.

REMEMBER – YOU MUST HAVE YOUR NABP CPE NUMBER TO COMPLETE THE EVALUATION Initial Release Date: 10/2/2019

91 | DATE | PRESENTED BY: SLIDES WILL BE POSTED ON THE WEBSITE www.gatewayhealthplan.com/ provider/provider- resources/educational-tools

CME credit only for enrolled participants in live webinar