The Transition 4th Year Pharmacy Students Entering the Real World of Pharmacy VOLUME V, ISSUE I AUGUST 2017 INSIDE THIS ISSUE: Augusta: Beautiful from Amen Corner Region Spotlight 1 to the Corners of the Savannah I can’t help but smile and laugh staff. It’s hard to imagine a bet- questions and provide guidance when I hear people refer to ter group of mentors and role to students seeking a postgradu- Agent to Watch: 2 “Disgusta”. It’s a misnomer for a models. Whether it’s talking ate residency. This has led to Andexanet Alfa city that most people never about sports with Dr. David greater residency interest and a truly experience. Sure, it Deremer, who will be sorely general feeling of being more doesn’t have the bright lights of missed, asking Dr. Clemmons prepared for the next steps. Atlanta or bustling nightlife of clinical questions, having confi- Amazon Pharmacy: If I could go back and do it all 3 Athens, but it contains the most dence replenished by Dr. Fagan, Prime Shipping again, knowing then what I sacred playing field of sports in or seeking life advice and moti- Your Prescriptions know now, I would rank Augus- the world, shares part of the vation from Drs. Dianne and ta as my top choice ten times strongest river in Georgia, and Rusty May, the open-door poli- out of ten. The people here Calculation Review 3 has one of the largest man-made cy in Augusta has benefited all of have helped shape me as a per- lakes in the country. us at some point or another. son as well as a future pharma- I was born in University Hospi- Take away the shiny new build- cist. So again, all I can do is tal in January of 1993, and Au- ing, the proximity to the hospi- smirk when I hear people refer Lifestyle Corner: 4 gusta has been home ever since. tals, and the networking oppor- to this beautiful city as Stay Fit While You Augusta, to me, is the city that tunities; the Augusta campus “Disgusta.” Sit everyone says they can’t wait to would still be unparalleled be- leave, but no one ever really cause of those who are com- pletely dedicated to their stu- Narcan® to the does. Ask anyone from Augusta, 4 dents in all areas of life. Rescue! and they’ll tell you their family is rooted generations deep in that Aside from the faculty and staff, red Georgia clay. Even more so, the Augusta campus offers a few Augusta features an expansive other unique perks to aid the Rotation Spotlight 5 medical district that rivals any development of future pharma- http://news.uga.edu/releases/article/pharmacy-opens-new- other in the southeast. With six cists. One of these is the ability educational-facility-in-augusta/ hospitals in a twenty-mile radi- to participate in research with us, it’s hard to imagine a better Dr. Segar, Dr. Shenoy, and Dr. place to live for any healthcare Fagan. In fact, full size labs are professional. So what does it being added onto the campus to offer a pharmacy school stu- facilitate student involvement in dent? For me, coming back as a research opportunities. Students student has revolutionized my have been able to make presen- view of the city. tations and contribute publica- https://steamcommunity.com/sharedfiles/filedetails/? Ask any student assigned to tions for novel research in these id=501724370. Accessed August 9, 2017. Augusta what makes the campus labs. Another perk is the vast Written By: Daniel Anderson so special, and I can guarantee network of clinical pharmacists (Augusta, GA) they’ll start with the faculty and who have volunteered their time as mentors to answer P A G E 2 Agent to Watch: Andexanet Alfa Many have heard of Andexanet alfa, yet the agent is not cur- centage of reduced anti-factor Xa activity and the percentage rently FDA-approved. The highly anticipatory nature sur- of effective hemostasis seen in patients who received andex- rounding this agent stems from its potential role of serving as a anet alfa. In regards to safety, an initial bolus and subsequent 2- reversal agent for major bleeds associated with the factor Xa hour infusion of andexanet alfa markedly reduced anti-factor inhibitors class like rivaroxaban or apixaban. Currently, only Xa activity, with effective hemostasis occurring in 79% of pa- two FDA-approved agents exist as reversal agents for antico- tients. However, the study is still awaiting full enrollment to agulants: Idarucizumab (Praxbind®) for dabigatran and Vitamin provide adequate statistical power to support a positive rela- K (phytonadione) for warfarin. The lack of a reversal agent for tionship between andexanet alfa and reduction in anti-factor factor Xa inhibitors is apparent to practitioners right now. Xa activity with clinical hemostatic outcomes. Furthermore, it Therefore, it will become important for pharmacists in all set- was reported that 18 of 67 patients experienced a thrombotic tings to understand the properties of Andexanet alfa if and event or death after being treated with andexanet alfa over a when it becomes FDA- 30-day study period, approved and makes its though the study acknowl- way into the market. edged that a controlled study would be needed to Andexanet alfa is a re- assess whether the fre- combinant modified hu- quency of these events man factor Xa decoy exceeded what is ex- protein. It simply func- pected in patients who tions by acting as a decoy have increased thrombotic for factor Xa without risk.2 having any intrinsic cata- lytic activity.1 By doing In the realm of anticoagu- so, factor Xa inhibitors lation, factor Xa inhibitors bind the decoy protein have their own unique set instead of binding human of advantages: minor drug Portola Pharmaceuticals Andexanet Alfa Mechanism of Action (MOA) Video Sep 12, 2014 https://www.youtube.com/watch? factor Xa. Theoretically, v=LXA7aIAA7yQ and food interactions, a this should decrease plasma lack in the need for lab levels of unbound factor Xa inhibitor and decrease anti-factor monitoring, and convenience of use.1 It will be interesting to Xa activity, which are the main efficacy outcomes being investi- see how the introduction of a reversal agent such as andex- gated in the ANNEXA-4 study currently underway.2 anet alfa will affect the utilization of factor Xa inhibitors. This implication makes the ongoing ANNEXA-4 trial interesting to The ANNEXA-4 study began in 2014 to examine the efficacy pharmacists because it will serve as a resource when faced and safety of andexanet alfa in patients experiencing a poten- with questions about the appropriateness of these effective tially life-threatening acute major bleed associated with factor but dangerous agents. Xa inhibitors. As of 2016, 67 patients have been evaluated and a descriptive preliminary analysis was published in the New Written by: Andrea Tse (Atlanta, GA) England Journal of Medicine (NEJM).2 Reviewed by: Mindi Miller, PharmD BCPS This analysis reported findings on endpoints including the per- Anticogulant Mechanism of Action Reversal Agent Warfarin (Coumadin®) Vitamin K Reductase Inhibitor Vitamin K, Prothrombin Complex Concen- trate (Kcentra®) Enoxaparin (Lovenox®) Vitamin K Reductase Inhibitor No reversal agent currently approved Dabigatran (Pradaxa®) Factor VII and VIII Inhibitor Idarucizumab (Praxbind®) Rivaroxaban (Xarelto®) Factor Xa Inhibitor No reversal agent currently approved Apixaban (Eliquis®) Factor Xa Inhibitor No reversal agent currently approved Edoxaban (Savaysa®) Factor Xa Inhibitor No reversal agent currently approved Betrixaban (Bevyxxa®) Factor Xa Inhibitor No reversal agent currently approved THE TRANSITION P A G E 3 Amazon Pharmacy: Prime Shipping Your Prescriptions As we begin preparing for life after pharmacy school, there are rise in pharmacy schools? More importantly, how will this affect several avenues available. Some of us will match for residencies; the job market that we will be facing in less than a year? Fortu- some will find jobs with retail chains, independents, or hospi- nately, with laws and regulations, Amazon will not be able to tals; and some may even have the oppor- function without pharmacists approving tunity to work for Amazon in the near prescriptions, transferring prescriptions, future. The well-known, fast-growing and navigating electronic prescriptions. electronic commerce (e-commerce) In addition, Amazon has already initiated company has meetings every year to a smaller model of pharmacy involve- discuss its potential role in the pharmacy ment in Japan, where they expanded the industry. This year, the meeting became popular prime delivery service to offer more serious as Amazon hopes to hire a drugs to patients with pharmacists’ ap- general manager to spearhead this new proval. Therefore, pharmacists will be endeavor. integral in the future pharmaceutical With retail, hospital, mail order pharma- component of Amazon’s industry. cies, and delivery services, why would Once a general manager is hired to or- patients turn to Amazon for prescrip- ganize and solve any issues that may tions? Many of us take advantage of Ama- arise, Amazon will be looking at a $25- zon to order school supplies, gifts, books, 50 billion dollar market associated with and more. By entering the pharmacy their involvement in the United States’ market, Amazon hopes to target patients massive pharmaceutical industry. If Ama- who either have high dollar deductible zon is able to offer convenient, cost- plans or who self-pay for their healthcare. https://medium.com/@jajaliao/if-amazon-takes-over-prescription-drugs-whats-left- effective prescriptions for patients and From this perspective, Amazon would for-startups-172a715c6e9c utilize an adequate number pharmacists find its niche in the multibillion-dollar as part of this endeavor, Amazon may be pharmacy industry in providing prescriptions at a lower cost looking at their next successful business scheme, and some of than offered from pharmacy benefit management groups.