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					2002 Officers October 2002 VOL. 25, NO. 7
President E. Robert Feroli President Elect David A Kotzin Secretary Scott Mark Treasurer John Ness Immediate PastPresident Janet Mighty

The new Hyatt Regency Chesapeake Bay in Cambridge, Maryland was a spectacular location for the 37th Annual Seminar, which was a sold-out success. The trade show hosted a record 30 exhibiting companies and organizations. After the opening general session, participants were treated to an enjoyable wine tasting presentation and sampling coordinated by Jerry Siegel, from the Ohio State University Hospitals. Affiliate relations installed the 2003 Officers and Board members. They are: Dave Kotzin - President Bruce Gordon - President-Elect Scott Mark - Secretary John Ness - Treasurer Jeffrey Brewer - Board Member Dennis Ebert - Board Member Laura Mark - Board Member Dave Kotzin is now looking for individuals to assist on various committees including; monthly programs, annual seminar, newsletter publications, public affairs and legislative. Anyone wishing to take part in these committees please call the MSHP headquarters at 410/465-9975 or send email to Mark your calendars to go back to the gap for the MSHP 38th Annual Seminar, October 10 - 12, 2003 at the Rocky Gap Lodge & Golf Resort, in Cumberland Maryland.

Board Members at Large Saturday and Sunday’s continuing education sessions offered state of the art information in the four areas of stud y; cardiovascular , Bruce Gordon neuro/psychology, oncology and infectious disease. Laura Mark Bonnie Pitt The continuing education programming concluding with an up to the minute presentation from Dr. Publications Committee Trish Perl of The Johns Hopkins Hospital on bioterrorism. Editor in Chief Brian L. Pinto INSTALLATION & AWARDS BANQUET Editorial Staff The highlight of the Annual Seminar was the Hye Kim Awards & Installation Dinner held in the hotel ballroom on Saturday October 12th. MSHP Headquarters 8480-M Baltimore National Pike, #252 Ellicott City, MD 21043 410/465-9975 FAX: 410/465-7073 E-Mail: Website: The MSHP Annual Awards were presented to honor those individuals who have made outstanding contributions to the pharmacy and to MSHP. This year’s award recipients are as follows: Pharmacist of the Year - Cynthia Boyle W. Arthur Purdum Award - Mayer Handelman Board of Directors Award - Kathleen Truelove Jeffery E. Ensor Leadership Award Jeffrey Brewer Pharmaceutical Representative of the Year Eileen Wilson, Roche Laboratories Past President’s Award - Bob Feroli

WELCOME NEW MEMBERS Jeanne Arnold Amanda Baumer Judy T. Chen Rudolph Choich, Jr. Amy Hatfield Jawara Kasimu-Graham Tyree Heath Kiser IV Cheryl A. Lieb Elizabeth McEvoy Karla Michelle Miller Vivian Park Patricia A. Ross Shailja Singh Leah Trimble John R. Tunney Anne Zichterman

The views expressed by contributing authors do not necessarily reflect those of the affiliated institutions of The Student of the Year Award will be presented MSHP unless expressly early in 2003. stated.

Hannah Kim, ASHP Director of Member and

Warfarin Sodium Induced Alopecia Manina Kaur, Pharm.D., Candidate and Mark Kern, Pharm.D., CACP, CDM-A/C
Hair loss secondary to medication use may pose a challenge to the care provision to any patient. This is especially the case in a patient initiated upon Warfarin sodium therapy. Provision of pharmaceutical care requires vigilance to this possible side effect in a patient requiring Warfarin therapy and an understanding of the mechanism and treatment options. Coumadin® (Warfarin sodium) is an anti-coagulant used in the anticoagulation treatment protocols for deep vein thrombosis, pulmonary embolism, stroke, and valvular heart disease. Its primary mechanism of action includes blocking synthesis of vitamin K dependent clotting factors 1 utilized within the clotting cascades. Common side effects we are most familiar with include headache, dizziness, weakness or bleeding. One of the uncommon side effects is alopecia or hair loss. 1 The prevalence of coumadin-associated alopecia ranges from.06% to 42% in the literature.2,4 In the earlier studies, Fischer et. al. reported a diffused pattern of hair loss in 42% of patients receiving coumarin. 2 This percentage is much higher than what has been reported in later studies. In this study, the duration of treatment did not affect hair loss. No age group was prone to experience hair loss, but women were favored slightly. The hair loss became evident after 8 weeks of treatment and the alopecia lasted six weeks. Later that year, Cornblett et. al. published a case report of diffused alopecia in a two-year old African American girl, who accidentally ingested a pesticide called “D-con” whose active ingredient was a coumarin. 3 Seventeen days after the ingestion of rat poison, the mother noticed that her child was loosing hair. She showed a diffused hair loss from the scalp, eyebrows, and eye lashes. After the accident, the maximal hair loss was seen on a 21st day and the hairs were fully regrown by 51 st day. In 1988, Umlas et. al. reported three case reports of warfarin-induced alopecia out of 5000 (.06%) warfarin treated patients during the past 40 years in their group practice. 4 The first case was a 62-year-old female, who was taking 2.5mg of warfarin daily for past ten years for mitral valve replacement. Alopecia occurred in the final year, and she noticed hair growth six months after the discontinuance of warfarin. Due to the complication of an embolic stroke, warfarin was reinstated, and the alopecia returned. The second case involved a 55 years old male who was taking 10mg of warfarin daily for past thirteen years. He was diagnosed with alopecia thirteen years later. In the third case, a 65 years old female was taking 2.5 mg of warfarin daily for past fourteen years, and noticed hair loss after eighteen months of therapy. Their results differed from the earlier findings of Flesch et al. They reported a much lower incidence, and late onset in years as opposed to weeks. However, the finding that high dosage
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Maryland Society of Health-System Pharmacists Monthly Program

"LMWH Horizons: New Uses, New Evidence, New Agents”
Sponsored through an unrestricted educational grant from Aventis Pharmaceuticals

Thomas S. Sisca, Pharm.D., FCCP, BCPS
Clinical Pharmacist, Drug Information Service, Drug Protocol Service, Outpatient Clinical Anticoagulation Service Shore Health System, Easton, Maryland.

Tuesday November 12, 2002 Liberatore’s
9515 Deereco Road, Timonium, Maryland
Schedule: 6:30 p.m.: Registration 7:00 p.m.: Dinner 7:15 p.m.: Business meeting 7:30 p.m.: Dr. Sisca’s Comments
University Pharamcotherapy Associates, LLC is accredited by the American Council on Pharmaceutical Education (ACPE) as a provider of continuing pharmaceutical education and complies with the Criteria for Quality for continuing pharmaceutical education programming. This program provides 1.0 contact hour (0.1 CEU) of continuing pharmaceutical education credit (ACPE UPN 786-000-02-003-L01). Upon attendance at the entire program and completion of appropriate forms, statements of pharmaceutical education credit will be mailed within 45 days of completion of the program. Original program release date is March 2002.

Objectives: Upon completing this program participants should be able to: 1. Differentiate the pharmacologic characteristics of low-molecular-weight heparins (LMWHs) as well as
2. 3. fractionated heparin (UPH); discuss the latest evidence for medical prophylaxis, q8hr vs. q12hr UFH, acute coronary syndromes , bridge therapy, and once daily regimens for VTE treatment; describe the role of fondaparinux and other investigational agents.


**Advance registration is required for this meeting**
Please respond to MSHP Headquarters NO LATER THAN TUESDAY NOVEMBER 5, 2002 Phone: 410/465-9975, fax: 410/465-7073, or E-mail: COST: Free for MSHP members, $30 for non-members and guests Directions: Take I-83 to Timonium Road (Exit 16B), keep left at the fork in the ramp, turn left onto Greenspring Drive.
Greenspring Drive becomes Deereco Road.

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may not necessarily result in alopecia is consistent with an earlier finding of Fischer et al. At the time of the earlier case reports, the mechanism of Warfarin-associated alopecia was unknown. Currently, it is believed that coumadin affects the hair follicle via a premature arrest of rapidly dividing cell, termed Telogen Effuvium. 5 To understand Telogen Effuvium, it is important to understand the normal hair follicle life cycle. Normal hair follicle undergoes three different cycles: anagen, catagen, and telogen. 5 The anagen phase, which can range from 4-8 years depending on the different hair (scalp hair, axillary hair, etc.), is characterized by intense mitotic activity. The catagen phase is a transition phase, and the telogen phase is the final phase, where hair shed. Coumadin causes hair to enter the telogen phase prematurely (Telogen Effuvium). As a consequence of premature arrest, excessive hairs are shed from the scalp. The resulting alopecia is diffused, non patchy, and asymptomatic. 6 Clinically, the alopecia is primarily on the scalp, but it has also been reported on eyebrows, and/or eyelashes. 6 Alopecia may or may not be noticeable depending on the percentage of involved follicles. The onset of alopecia may range from several weeks to years after the start of coumadin therapy. 2-4 Incidents of alopecia with concurrent administration of H-2 Receptor Blockers with Warfarin have been reported to the FDA on numerous occasions.7,8,9,10,11 Coumadin-associated hair loss is a temporary and benign condition that does not usually require any treatment; however, when it has to be used chronically in genetically alopecia predisposed patients, treatment with topical Minoxidil may be helpful. 5 In the future, a possible treatment option may include ubidecarenone, which was originally developed to improve

cardiac metabolism in heart failure. 12 It looks promising in coumadin-induced hair loss. 12 One may conclude that Coumadin-induced alopecia has been reported in the literature, and it primarily affects the anagen phase of the hair cycle; thus, putting the hair follicle in telogen phase prematurely. Coumadin does not affect the catagen phase. No age group is more prone to develop hair loss, but women are favored somewhat. Additionally, there is no relationship between dose or duration of treatment with hair loss; however, it is clear that the alopecia is reversible and of diffused pattern. REFRENCES Lacy CF, Armstrong LL, Goldman MP, et. al. Drug Information Handbook Lexicomp Publishers, Cleveland, 2001-2002 (9th edition) . 2. Fischer R, Bircher J, and Reich T. Alopecia from anticoagulant therapy. Schweiz med Wchnschr 1953;83:509-11. 3. Cornblett R, Leonard H. Alopecia from coumarin. Arch of Dermatol 1953;75:440-41. 4. Umlas J, Harken DE. Warfarin-induced alopecia. Cutis 1988;42:63-64. 5. Tosti A, Misciali C, Piraccini BM. Drug induced hair loss and hair growth. Drug Saf 1994;10(4):310-17. 6. Maguire HC. Drug induced alopecia. Clin Pharmacol 1979;19(1): 178-80. 7. bl.pdf 8. 9. 10. 11. 12. Nagao T, Ibayashi S, Fujii K. Treatment of warfarininduced hair loss with ubidecarenone. Lancet 1995;346:1104-5. 1.

Maryland Society of Health-System Pharmacists 8480-M Baltimore National Pike, #252 Ellicott City, MD 21043

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