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H OLLADAY H EALTHCARE P HARMACY
H OLLADAY HAPPENINGS
V OLUME 13, ISSUE 1
W INTER 2103
U NDERSTANDING C ARDIAC E NZYMES
By N. Joyner
Cardiac enzymes
are proteins released
from the heart in response to damage. These
enzymes are used to rule
in or rule out certain
events, such as a myocardial infarction. The three
cardiac enzymes used are
myoglobin, creatinine
kinase, and troponin.
Myoglobin is
found in both the heart
and skeletal muscle. It is
released during injury.
The levels of myoglobin
peak early and can be
used for early detection.
Myoglobin levels usually
return to normal within
24 hours of an MI. How-
ever, myoglobin may also
be elevated due to injury
to the skeletal muscle.
There are
three different types
of creatinine kinase.
CK-MM is found in
skeletal muscle, CKBB in the brain, and
CK-MB in the heart and
skeletal muscle. CK-MB
is used to identify if a patient has had injury to the
heart. CK-MB is more
specific than myoglobin;
however, it may also become elevated due to
injury to the skeletal
muscle.
There are three
types of troponin, tro-
ponin C, troponin I, and
troponin T. Troponin is
the most specific and sensitive of these cardiac enzymes. It is useful for
determining if a patient
has had a myocardial infarction hours after it has
occurred. Levels peak
within 24-48 hours and
return to normal in 5-10
days.
Nina Joyner is a PharmD Candidate at
Wingate University.
S PECIAL POINTS OF
INTEREST :

Dementia is not the
only cause of forgetfulness. Check out page 3
to learn more.

Quiz yourself on medication safety on page
4.

Holladay has changed
our cut-off times and
hours of operation to
better serve you. Page
5 has more details.

Need CEU hours?
H.E.L.P. 2013 Registration is inside!
I NSIDE THIS ISSUE :
E XELON P ATCH
2
CMS M EMO
2
I S IT D EMENTIA ?
3
P ROBIOTICS
4
QUIZ
4
N EW TIMES
5
H.E.L.P.!
6
V ISIT US AT THE E XPO !
Roll out the red carpet:
Holladay Pharmacy & Holladay Surgical
Supply will both be exhibiting at the NC Health
Care Facility Association
(NCHCFA) trade show
on Tuesday, February
12th, 2013.
This year’s expo
is being held at the Sheraton Greensboro Hotel at
Four Seasons. The theme
is “Lights, Camera, Expo!”
Receive VIP treatment
when you stop by and
visit with the star-studded
celebrities of Team Hol-
laday. Holladay’s experienced staff will treat
YOU like a shining star.
As always, a
great door prize will be
offered. Don’t forget to
register. You may be the
lucky winner!
H OLLADAY
P AGE 2
HAPPENINGS
E XELON P ATCHES (R IVASTIGMINE T RANSDERMAL )
By C. Teeter
Exelon patches are
indicated for the treatment
of mild/moderate Alzheimer’s dementia and mild/
moderate Parkinson’s dementia. Rivastigmine is a
reversible cholinesterase
inhibitor that is thought to
exert its therapeutic effect
by enhancing cholinergic
function.
Exelon Patches are
indicated for dementia
caused by Alzheimer’s
Disease or
Parkinsonism.
The initial dose of
Exelon Patch is 4.6mg/24
hours for 4 weeks and increased to 9.5mg/24 hours
if the dose has been well
tolerated. Continue on
this dose as long as therapeutic benefit has been
demonstrated. The patient
may be increased to the
maximum dose of 13.3
mg/24 hours. The maximum dose recommended
for patients with moderate
to severe renal impairment
(GFR<50ml/min) AND
for mild to moderate hepatic impairment (Child
Pugh Score 5-9) is
4.6mg/24 hours.
The most common
side effects are gastrointestinal including significant
nausea, vomiting, diarrhea,
anorexia, and weight loss.
The incidence of these effects are dose related and
are more severe in patients
with low body weight
(<50kg). Therefore it is
important to titrate the
dose carefully as indicated
above and to monitor carefully any patient who is
frail. If dosing is interrupted for one to three days,
restart treatment with the
same dose. If it has been
longer than three days,
restart titration with
4.6mg/24 hour patch.
Medication errors
with Exelon Patches have
resulted in serious adverse
reactions. The majority of
the errors have involved
NOT removing the old
patch when applying a new
one. The patches must be
applied firmly to a clean,
dry, hairless area that will
not be rubbed by tight
clothing. The application
site should be rotated and a
new patch should NOT be
applied to the same area for
at least 14 days. Possible
application sites are upper,
mid and lower back and
upper arms or chest (if patient is not likely to remove the patch.) The site
of application should be
recorded on the MAR.
Candice Teeter, R.Ph., is a consultant
pharmacist with Holladay Pharmacy.
N EW CMS G UIDELINES
CMS
HAS ISSUED
CLARIFICATIONS
THAT
NECESSITATE
PRACTICE
CHANGES IN THE
INDUSTRY
On November 2, 2012, CMS
released a memorandum (Ref: S&C: 1302-NH) titled “Nursing Homes—
Clarification of Guidance related to
Medication Errors and Pharmacy Services.” This memo discussed CMS’s
stance on several issues pertinent to long
-term care including proper procedure
for medications given per tube, timing of
medication administrations, and borrowing and disposal of medications. Expectations regarding medication regimen re-
views for short-term residents were also
clarified.
Holladay Healthcare Pharmacy responded immediately to these new guidelines. We initiated education for our facilities, updated our practice tools and modified our policies and procedures to reflect
the changes. Your Holladay Healthcare
consultant pharmacist can give you a copy
of these regulations and provide guidance
on how these changes affect your current
practices.
H OLLADAY
P AGE 3
HAPPENINGS
I S IT A LZHEIMER ’ S OR S OMETHING ELSE ?
By J. Evans
With more than 5 million Americans affected by Alzheimer’s Disease
(200,000 under age 65), it’s definitely
frightening anytime we suffer a memory
lapse. However, there are many situations and conditions which may cause
memory disorders. The following list
contains 8 possible causes for memory
loss and other symptoms which might
resemble Alzheimer’s Disease:

Chronic Stress – Chronic tension
and anxiety overloads our systems
causing the brain to actually lose
cells and have trouble forming new
neurons. This creates problems with
cognitive thinking and the ability to
retain new information.

Depression – Concentration and
focus are affected by low serotonin
levels causing an impairment in the
ability to store new information and
memories. When depression symptoms are treated, the memory problems often disappear.
“P EOPLE WITH
A LZHEIMER ’ S
D ISEASE ARE
OFTEN UNAWARE
T HAT THEY ARE
HAVING MEMORY
PROBLEMS .”


Medications – Many drugs affect the
ability of brain cells to communicate. The addition of new drugs,
dose changes, or interactions between drugs may cause memory
problems. Some drugs which affect
memory are: statins, sedatives, antianxiety drugs, and drugs for urinary
incontinence.
Thyroid Disorder – Low thyroid
levels decrease metabolism and affect the entire body, including the
brain.

Pregnancy or Menopause – Changing
estrogen levels at key points in a woman's reproductive life can affect brain
chemical levels. Memory problems
tend to be worse from the second trimester through three months postpartum. Not all women are affected.

Excessive Drinking – heavy drinking
damages the liver and kidneys. Imaging
studies have shown brain impairment
occurs also. Loss of neurons causes
potential brain shrinkage, especially in
the frontal lobe which governs higher
intellectual functions, and other structures involved in memory. Excessive
drinking may cause a condition called
Korsakoff Syndrome – a form of alcohol induced dementia.

Concussion / Head Injury – a traumatic
brain injury may occur following a fall,
sharp blow to the head, or by an object
piercing the skull. Memory problems
are usually sudden and dramatic, following a history of trauma. Other
symptoms might be numbness, drowsiness, headache, weakness, dizziness and
slurred speech.

Normal Aging – Memory lapses may be
NORMAL!! Occasional forgetfulness
does tend to increase as we get older.
People with Alzheimer’s Disease
are often unaware that they are having
memory problems. If you’re worrying, you
may be just fine, experts say!
Jerry Evans, Pharm.D., P.A., is a consultant pharmacist with
Holladay Pharmacy.
H OLLADAY
P AGE 4
HAPPENINGS
T HE P ROS & C ONS OF P ROBIOTICS
Probiotics can be
found naturally in
foods or in manufactured forms.
Probiotics are dietary supplements composed of microorganisms
marketed to be beneficial
to health. They are often
used to treat gastrointestinal disorders such as diarrhea or constipation. They
may also provide prophylaxis against antibioticassociated diarrhea.
Other disorders
have been treated with probiotics. These include allergy-related problems
such as atopic dermatitis,
allergic rhinitis, asthma,
and lactose intolerance.
Disorders related to harmful bacterial overgrowth
such as bacterial vaginosis
or H. pylori peptic ulcer
disease are also reasons
probiotics are given.
Probiotics can be
found naturally in food
products such as yogurt and
kefir. They are also manufactured as tablets, capsules, and powders. There
are not clear guidelines on
which strains are best for
certain disorders. It is important to remember that
the FDA has not approved
probiotics for any indication at this point.
The use of probiotics should be continually
reassessed for need. For
example, if a patient is
started on a probiotic supplement with an antibiotic,
the probiotic should have a
stop date. It should not
continue indefinitely after
the antibiotic is discontinued.
M EDICATION S AFETY Q UIZ
By J. Higgins
Word Choices:
Annually, Crushed, Expired, Illegal,
List, Misuse, Not, Poisonings
Test your knowledge
of safe medication
practices!
Use each word once:
1. I should _______ take medicine
for non-medical reasons.
2. Sharing prescription medication
is ________.
3. Prescription drug _________ is
when I take my medication
differently than prescribed.
4. ________, I should get a review of
my medications by my pharmacist
and physician.
5. Not all medications are able to be
_________. Check with your pharmacist with any questions.
6. I should always carry my medication ________.
7. Accidental __________ can occur
when old medications are kept in
the home.
8. I should dispose of _________
medications properly.
https://
www.smarxtdisposal.net
Jessica Schmidt Higgins, Pharm.D., is a consultant pharmacist with Holladay Healthcare Pharmacy.
Answers to Quiz: 1. Not 2. Illegal 3. Misuse 4. Annually 5. Crushed 6. List 7. Poisonings 8. Expired
V OLUME 13,
ISSUE
1
P AGE 5
H OLLADAY E XTENDS C UT -O FF T IMES
Our customers asked and Holladay
delivered! We recognize that LTC is constantly changing. Many of our facilities are
receiving new residents later in the day and
many of our LTC prescribers are rounding
and placing orders later in the day.
2. The order must be signed. If the order is a telephone or verbal order, the
order must be indicated as such and
signed by the authorized person receiving the order and include the prescriber’s name.
In order to better serve you, Holladay Pharmacy has extended our cut-off
times for both new orders and refills.
3. If the orders are for a new admission/
readmission, please include a statement
that orders have been verified by the
prescriber.
New Order Cut-Off Time:
Monday-Friday: 5PM
Saturday:
3PM
Refill Cut-Off Time:
Monday-Friday: 3PM
Saturday:
10:30AM
Tips for Ensuring Timely Delivery of New
Order Medications:
1. All orders need to be spelled out correctly and completely. This should include
the following:

Name of facility

Full name of the resident

Prescribing physician

Name of the medication and
strength

The directions for use

The reason the medication is
being used (Holladay would like
to have this for ALL medications
to provide the best pharmaceutical care. It is required for PRN
medications by guidelines.)
4. If the medication is needed and it is
after cut-off, please call Holladay Pharmacy to make arrangements for the
medication to be delivered.
Tips for Ensuring Timely Delivery of
Refills on Medications:
1. Pull the bar code refill label as soon
as either the red re-order flag in the
medication box or the re-order
point on the punch card is reached.
For facilities using eMAR, select the
“refill” button on your computer
when the reorder point is reached.
2. With a paper MAR system, fax the
page of bar code labels as soon as
possible. Do NOT wait to fill up the
page.
3. If the medication is needed and it is
after cut-off, please call Holladay
Pharmacy to make arrangements for
the medication to be delivered.
Holladay Pharmacy also extended our hours of operation on Saturday
from 8:30am to 3pm last fall. We are
available to take your call on our regular
line from 8:30am-5pm Mondays through
Fridays as well. As always, a licensed
pharmacist employed by Holladay Pharmacy is available to take your call after
hours on our on-call number.
Holladay Pharmacy
understands your time is
valuable!
QUESTIONS OR COMMENTS?
Email [email protected]
Holladay Pharmacy
celebrates 30 years of
service to NC LTC in 2013!
W WW. HOLLADAYCARE. COM
W E’ RE
ON THE
W EB!
2560 Landmark Drive
Winston-Salem, NC 27103
Hours of Operation
8:30am-5:00pm Monday-Friday
8:30am-3pm Saturday
Toll Free: 800-848-3446
Local: 336-760-3446
Fax: 800-858-9372
H OLLADAY H EALTHCARE
P HARMACY
H.E.L.P. IS ON THE W AY !
Mark your calendars…the dates have been
set for Holladay’s Educational Learning Program
(H.E.L.P.)! This annual
event will be held on
Thursday, April 11th and
Friday, April 12th, 2013.
This seminar is one of the
most popular in the state!
H.E.L.P.2013
will again be held in
Greensboro at the Proximity Hotel. The Proximity is one of the “greenest”
hotels in America and offers a unique design and
location close to Greens-
boro’s finest restaurants
and shopping. A block of
rooms, at a reduced rate,
has been reserved at this
eco-friendly, award winning hotel.
This year’s event
will be offering 8 – 10
hours of CE credit hours
to both administrators and
nurses. The agenda will
focus on topics pertinent
to Long Term Care
(LTC), including Safe
Staffing Principles, Documentation and Medication
Errors, Changing Culture
of LTC, Benefits of Music
Therapy and much more.
Plus, the conference offers
an outstanding networking
opportunity with peers
throughout North Carolina.
The cost of the
entire program is only
$50.00 and includes lunch
both days. To register,
please return the registration form inserted in this
newsletter or call Holladay
Pharmacy (Susie Tickle) at
(800)848-3446 as soon as
possible. This event has
sold out in past years and
space is limited. We encourage you to register
early!
Our 2013 H.E.L.P. seminar
offers timely insights and
connections with others to
help you navigate the challenges of the long-term care
environment!