Download Trigeminal Neuralgia

Volume
Volume 14,
12, Issue
Issue 62
PHARM NOTES
November/December
2011
Neil Medical Group: The Leading Pharmacy Provider in the Southeast
Neil Medical Group: The Leading
Trigeminal Neuralgia
Background
Trigeminal neuralgia, also known as Tic Douloureux, is an extreme
burning, shock like pain in the face. The trigeminal nerve is the
nerve that is affected which branches into 3 different parts that link
the brain to the face. Upper part (ophthalmic) links the brain to the
scalp and forehead, while the middle branch (maxillary) connects the
teeth, gums, upper jaw, nose, and top lip. The lower branch
(mandibular) connects the lower jaw, teeth, bottom lip and gums.
The pain typically is located in the lips, gums, cheek, or chin and
rarely in the ophthalmic branch. In most
cases, the pain will be one-sided; however, it
may present on both sides, but not usually at
the same time. The pain may last from several seconds to a minute or two. Despite the
short time length, the pain is very intense
with co-morbidities including depression and
anxiety due to anticipation of a recurrence.
Facial spasms may also occur. The pain will
typically recur in clusters throughout the
day for weeks at a time with patients having
no pain between episodes. The pain may
subside and not recur for months to years at
a time.
Pharmacological Treatment
Carbamazepine is the treatment of choice and is the only drug that is
indicated for trigeminal neuralgia. It is effective in nearly 50-75% of
patients with a total of 88% having a reduction in attacks by more
than 50%. There is an increased risk for adverse effects which include: dizziness, giddiness, unsteadiness, sedation and somnolence.
Rare cases of agranulocytosis have also been reported. Oxcarbazepine is similar to carbamazepine and due to fewer side effects,
may be used more often. It has shown equal efficacy in one clinical
trial. Measuring the efficacy of carbamazepine and oxcarbazepine is limited due
to the significance of adverse effects and drug
interactions. Taper should be attempted after
1 to 3 months. Several other medications are
used for the treatment of trigeminal neuralgia,
but efficacy is uncertain and more studies are
needed to determine their place in therapy.
Various other anticonvulsants are often used
in the treatment of trigeminal neuralgia
(phenytoin, clonazepam, lamotrigine, valproic
acid, and gabapentin) though there are no large
scale controlled trials that show efficacy.
Baclofen, a skeletal muscle relaxant, may be
useful but is not indicated for this condition. It
may be used along with carbamazepine and
effects may be synergistic. Although carbamazepine is typically used first, some prefer
to use baclofen first due to fewer side effects.
There are trigger zones that can cause an
attack which can generate immense pain.
These zones can be triggered by light touch
or vibration, and this can prevent a patient
from allowing a full physical exam due to
the anticipation of pain. The physical examination should come back normal with no signs of sensory loss.
Pimozide may be more effective then carbamazepine but has only been studied in a single cross over trial.
This medication is not often used due to its side effect profile. These
Causes
side effects include: hand tremors, memory impairment, and involunThe cause of trigeminal neuralgia is not known, but there are several
tary movement. There have been few trials studying antidepressants
theories. The common opinion is that the pain is caused when the
and neuropathic pain, and few patients that have been studied with
nerve is pinched or damaged (blood vessel, lesions or tumor). Dental
trigeminal neuralgia. Amitriptyline has the most supporting evidence
fillings in the nearby area can also cause attacks. Age related brain
with 3 out of 9 patients experiencing at least moderate relief.
changes and increased thickness of vasculature are other suggested
Continued on page 5
causes. Many times the cause is unknown.
Inside This Issue:
Page 2
Page 3
Page 4
Page 5
Pages 6
Page 7
Page 8
Trigeminal
Neuralgia
Let’s Talk
TSH!
Artificial
Sweeteners &
Weight Loss
Supplements to
Prevent UTI’s
Conclusion:
Trigeminal
Neuralgia
Tardive
Dyskinesia
Medical
Calculations
Quiz
NMG Contact
Information
Let’s Talk TSH!
One of the most confusing labs we often review is TSH.
TSH is the acronym for Thyroid Stimulating Hormone.
It is produced in response to the function of the thyroid
gland and the possible need for thyroid supplementation. What makes this lab confusing is the thought process required for us to use as we review the lab results.
With most all other labs, when the value is below normal limits, we immediately know that a dose increase
will be necessary to get the medication to a therapeutic
level for the resident. Likewise if the value is above normal limits, we would expect a dosage reduction would
be ordered. Thus low labs are considered “hypo” while
high labs are considered “hyper” supplementation.
The purpose of the TSH is to “stimulate” the thyroid
gland to “work harder”. Thus, an elevated TSH indicates
the thyroid is low while a low TSH indicates the thyroid
is too high. With that in mind, when it comes to reviewing TSH labs we must reverse our thinking since the
logic for considering a dosage increase or decrease is
exactly opposite from what we would normally do with
common labs such as potassium, digoxin, magnesium
and Vit D. It is very easy to increase the levothroid supplementation when an actual dose decrease should have
occurred. It is most important that any time there is a
change in thyroid dosage, that all health care providers
(Prescribers, Nurses and Pharmacists) take a moment
and double check the order for validity. Excessive thyroid supplementation can lead to tachycardia, increased
BP and increased anxiety while under supplementation
would have the opposite effect. This is why we take the
pulse at least weekly with thyroid supplementation – to
make sure we are not giving the resident a medication
that is worsening his/her clinical condition.
Here is a clinical pearl that will provide you with an easy
way to remember whether a thyroid dose increase, no
change, or a decrease would be clinically appropriate
when reviewing TSH lab results:
“The direction the TSH is going is the
direction the dose needs to be going.”
To put this in practical terms, if the TSH is high, the thyroid dose needs to be higher because this is Hypothyroidism. Strange to increase a dose when the lab is high?
Remember the logic with reading TSH labs is the opposite of our other lab results. High TSH lab results indicate hypo. If the TSH is low, the dose needs to be lower
because this is Hyperthyroidism. If the TSH is WNL then
no dosage change is needed.
Let’s look at some examples and apply the clinical pearl
Let’s say normal TSH lab values are 0.5 to 4.5. Review
the following scenarios to determine whether:
A) the diagnosis should be Hypo- or Hyper- thyroid, and
B) a dose increase, no change or dose decrease would
be appropriate.
Example #1: TSH 12.5
Hypo or Hyperthyroid? Dose
Increase, No Change, Dose Decrease?
Example #2: TSH= 0.1 Hypo or Hyperthyroid? Dose Increase, No Change, Dose Decrease?
Example #3: TSH=3 Hypo or Hyperthyroid? Dose Increase, No Change, Dose Decrease?
Example #4: TSH=4.6 Hypo or Hyperthyroid? Dose Increase, No Change, Dose Decrease?
Example #1 the TSH is HIGH →Hypothyroidism. Since
the TSH is high, supplementation would need to be
higher. Thyroid dose increases should be done very
gradually so this is why we normally see daily increases
of only 25 mcg (micrograms). TSH lab would need to be
rechecked in 6-8 weeks to monitor this dosage increase.
Example #2, TSH is LOW →Hyperthyroidism. Since TSH
is low, supplementation would need to be lowered. Likewise, we would expect the dose to be decreased by 25
mcg and repeat TSH lab in 6-8 weeks.
Example #3, TSH is WNL so no dosage change would be
needed. TSH lab would be repeated in a year or per facility lab protocol.
Example#4, TSH is only slightly elevated. While the
dose could be increased, most likely no dosage change
would occur especially in our elderly population.
Hope this clinical pearl helps you the next time you review a TSH lab. If TSH is high, increase the dose. If TSH
is low, decrease the dose. If WNL, no dosage adjustment
would be necessary. Happy TSHing!
Article by Andy Hunter, RPh; Consultant Pharmacist
Neil Medical Group
Page 2
Neil Medical Group – Pharmacy Services Division
Artificial Sweeteners and Weight Loss
In their efforts to lose weight, individuals frequently
consume products containing non-nutritive sweeteners.
The US Food and Drug Administration (FDA) granted
approval for five such sweeteners: saccharin, aspartame,
sucralose, acesulfame, and neotame. In addition, stevia,
an herbal intense sweetener, has recently
emerged in the
U.S. marketplace. Each of
these sweeteners is many
times sweeter
than sucrose
or table sugar. For this reason, their caloric contribution
is minimal. The issue is whether consuming artificially
sweetened products helps people lose weight.
partame or sucrose pre-prandially (before a meal) enhanced human appetite.
The second avenue of inquiry expands on the mechanistic way the human palate perceives sweetness to its impact on the desirability of food and the behaviors associated with this perception. Inescapable from this examination is the understanding that, other motivations aside,
people tend to consume greater quantities of food that
tastes better to them. David Benton says that the difficulty in assessing this relationship reflects that “in reality
it is rarely possible to disassociate energy density and
palatability; attempts to do this have varied energy density over a very limited range.” Furthermore, individuals
who realize that they are consuming aspartame are likely
to consciously increase their caloric intake, “suggesting
overcompensation for the expected caloric reduction.”
Given the complexities of consumption patterns and motivations, researchers have yet to design and implement a
prospective randomized, controlled trial reflecting the
The rationale behind substituting a non-nutritive sweetmultivariate nature of the physiological and behavioral
ener for higher calorie sucrose and high fructose corn
influences quantifying the impact of non-nutritive sweetsyrup is mathematically simple and appealing: a reduceners on weight loss and applicable to the general popution in approximately thirty kilocalories per teaspoonful.
lation.
Using a practical example of this logic, an individual
who normally consumes two sugar sweetened soft drinks
daily at 150 kilocalories each could lose almost one
pound weekly just by substituting two zero calorie soft
drinks. As appealing and straightforward as this sounds,
research reveals a much more complex picture. In fact,
some studies have even indicated some level of correlation between artificial sweetener use and weight gain.
Many hypotheses have been generated to explain the
equivocal nature of conclusions regarding the impact of
non-nutritive sweeteners on weight loss or gain. The scientific literature on the topic of sweetness, satiety and
energy intake is split.
The more fundamental area of research focuses on the
qualitative differential physiological reaction of the brain
and the digestive system to nutritive and non-nutritive
sweeteners. The question for researchers is whether consumption of foods perceived as sweet but lacking in the
caloric content of natural sugars activate compensatory
mechanisms resulting in an unconscious physiological
stimulus to increase consumption to make up a perceived
deficit. According to Yang, experiments providing asNeil Medical Group – Pharmacy Services Division
By Gus Hodges, Pharm D Candidate
Page 3
Supplements to Prevent UTI’s
For many years various supplements have been used in the
attempt to prevent recurrent urinary tract infections (UTI). This
is a brief review of the current literature that supports (or lack of
support) the use of these agents.
Multiple factors predispose the elderly to frequent UTIs including hormonal changes, other medical conditions, medication
use, urinary incontinence, fecal incontinence, and poor perineal
hygiene. It should be noted that asymptomatic bacteriuria in
the elderly usually does not require treatment. In nursing
homes, it is estimated that 20-50% of residents without urinary
catheters and almost 100% or residents with urinary catheters
have bacteriuria. Therefore, urinalysis should generally only be
done when the resident has symptoms of UTI, and treatment
should be reserved for symptomatic residents in order to prevent bacterial resistance to antibiotics. Based on the high number of UTIs that do occur, some providers start various treatments to reduce the frequency of UTIs.
Vitamin C
The theory behind the use of Vitamin C/ascorbic acid to prevent
UTIs is based on acidifying the urine. One theory is that with
acidification, nitrite results in the formation of nitric oxide which
is toxic to some bacteria. A review of the literature for clinical
trials to support the efficacy of Vitamin C for the prevention of
UTIs yielded no good clinical trials showing Vitamin C to be an
effective preventative. So despite the fact that Vitamin C is often being given for the prevention of UTIs, there is little objective clinical data to prove efficacy.
Cranberry
Cranberry, especially concentrated formulations, has been proposed to prevent UTIs for many years. The theory behind the
efficacy is that cranberry prevents the adhesion of bacteria to
the epithelial lining of the bladder and therefore prevents infection. There is also vitamin C in cranberry extracts resulting in
the acidification of the urine. A new product UTI-STAT, which
is a concentrated cranberry liquid blend, is currently being marketed to LTC facilities for the prevention of UTIs. The
available study for
the claim of reduced
UTIs is based on 23
females with an average age of 46.5
years old taking 60
ml daily for 12
weeks. There was
no control group for
comparison, only a
comparison to historical UTI rates.
Therefore, it is unknown if this product
will be effective for
LTC facility populations.
Methenamine
Methenamine salts are often used for UTI prevention. According to Clinical Pharmacology, “In an acidic environment,
methenamine is hydrolyzed to ammonia and to formaldehyde.
The amount of formaldehyde released is directly proportional to
the pH of the environment; a greater amount of formaldehyde is
produced as pH decreases. Methenamine is commercially
available in combination with hippuric acid (Hiprex) or mandelic
acid (Mandelamine). These weak organic acids have some
antibacterial activity and also act to keep the urine acidic.
Plasma concentrations of either methenamine or formaldehyde
are generally low. It is believed that the formaldehyde denatures protein. Nearly all bacteria are sensitive to formaldehyde
if a critical concentration is reached. Formaldehyde is generally
bactericidal in action and is effective against a wide variety of
organisms. If the urine is not acidic, then methenamine will not
be activated. Despite the proposed mechanism of action, there
are limited studies that support efficacy. There are multiple
combination products that contain methenamine, but recently
these have been removed from Medicare D plan formularies
due to lack of any proven clinical benefit.
Page 4
Antibiotics
Most antibiotic classes with activity against typical microorganisms that cause UTIs remain the most clinically sound way to
prevent UTIs with medication. However, antibiotic use increases bacterial resistance and side effects. Therefore, antibiotics for suppression/prevention of UTIs should be used when
recurrent infections cannot be prevented with non-medication
means such as good hygiene, treatment of any underlying condition that is contributing, good toileting programs, etc.
In summary, agents for the prevention of recurrent UTIs generally lack good clinical trials proving the multiple proposed
mechanisms of action. Therefore non-medication means should
be addressed initially. However, given the increasing bacterial
resistance with antibiotic use, it might be appropriate to try vitamin C or concentrated cranberry products prior to committing
the resident to ongoing antibiotic therapy. If vitamin C or a concentrated cranberry product does not reduce the frequency of
UTIs for the resident, then the agent should be stopped.
Neil Medical Group – Pharmacy Services Division
Article by Amanda Byrd, Pharm D, FASCP
Trigeminal Neuralgia
continued from page 1
Referral should be done if symptoms are refractory to medications.
Radiofrequency thermal rhizotomy
If the patient has no symptoms of pain for 4-6 weeks, the medication • Causes damage to the specific nerve fibers using heat.
can be tapered.
• One of the more common procedures that is used.
•
Short term relief in nearly 95% of individuals, although long
term success is not achieved in 1/3 of individuals.
•
This procedure causes numbness of the face and masseter weakness.
•
Efficacy is based on small trials.
Injection with Alcohol
•
•
Based on a small trial with 98 people.
The conclusion of this study is that the injection with alcohol
can provide long lasting pain relief for those with pain in the mandibular region.
•
The probabilities of remaining pain free for 1, 2, 3, and 7 years
after the procedures were 90.4%, 69%, 53.5%, and 33%, respectively.
•
Surgery/Procedures
Surgery/procedures are indicated when symptoms are refractory to
medication. Most of these procedures do have high rates of success.
Micro vascular decompression
•
Patients that have more complications from the injection would
have longer pain free periods. Complications included paresthesia,
dysesthesia, masseter muscle weakness, heavy salivation or deep
sensory loss. All patients experience some form of complication.
•
This procedure is not used often and is not mentioned in the
guidelines.
Complementary medicine
Used to relieve pressure on the nerve as it exits the brain with
this pressure normally being caused from a blood vessel or tumor.
Complementary medicine, such as acupuncture, has been shown to
relieve pain, but there have been no extensive studies to support effi• It does have high initial success rates (>70%) and also may have cacy.
the longest duration of pain relief with 50% having pain relief for
Conclusion
three years following the procedure.
Carbamazepine and oxcarbazepine are the most studied medications
• It is able to preserve facial sensations, although in a few cases and may be the most effective in the treatment of trigeminal neuralgia. Carbamazepine
there has been damage to other nerves. Other side effects include
is considered the
major complications in 3 patients: death and brain stem infarct.
Common complications include: Meningitis, sensory loss, and long treatment of choice,
and oxcarbazepine
term hearing loss.
can be used if the
• Data is based on a trial with 1,185 patients.
side effects are intolerable. Other mediGamma knife-stereotactic radiosurgery
cations can be tried,
• High dose of ionizing radiation using beams to the targeted area such as pimozide and
baclofen, but have
of the brain.
not been extensively
• Least invasive procedure.
studied. Surgery is
• It is able to give complete pain relief in >2/3 of patients.
an option that can be
if the pain is
• Radio surgery can be used for those who have co-morbidities, used
refractory. For
high risk medical conditions or refractory pain following surgery.
emergency room and
• Complication is numbness caused by nerve damage, but this
short term use, sumatriptan and inhaled lidocaine have been shown to be effective and
occurs in only a few individuals.
be considered although neither have been widely studied in large
• There is not as much evidence for this surgery compared to the can
trials or for long term use. Trigeminal Neuralgia lacks studies in
micro vascular decompression procedures and it is also very expen- treatments causing difficulty in determining long term efficacy and
sive which limits its use.
safety.
Article by Joanna Woten, Pharm D Candidate
Wingate University
Neil Medical Group – Pharmacy Services Division
Page 5
Tardive Dyskinesia
Tardive dyskinesia (TD) is a neurological disorder characterized by repetitive involuntary, purposeless movements.
These movements are jerking, not rhythmic, and include
tongue thrusting, facial grimacing, jerking of the head, lip
smacking, mouth puckering, rolling of the tongue, or twisting
of the trunk. Patients may also appear to be playing an invisible piano when the arms are extended. Oddly enough,
symptoms subside when patients are asleep. Most cases of
tardive dyskinesia are mild and some may be reversible, but
others are irreversible and can be debilitating.
Tardive dyskinesia is caused by the use of certain classes of
medications. These classes include antipsychotics, antiemetics such as metoclopramide (Reglan) and promethazine
(Phenergan), and medications with
strong anticholinergic activity
such as tri-cyclic antidepressants
and diphenhydramine (Benadryl) .
The largest risk factors for developing tardive dyskinesia are the
exposure over time to the causative agent and the dose used.
Other factors which increase the
risk of tardive dyskinesia include
age (children and elderly), female
gender, smoking, alcoholism or substance abuse. Mental
retardation, diabetes, and a family history of TD are also risk
factors.
have activity at D1 and serotonin receptors as well. Because
of this additional blockade of other sites, the atypical agents
are considered by most practitioners to be less likely to cause
TD. This theory has only been proven for the atypical agent
clozapine (Clozaril). Clozaril has even been shown to reverse TD in some cases.
Treatment of tardive dyskinesia is aimed toward symptom
control. Unfortunately, there is no universally proven treatment for TD. The first step is to decrease or remove the
causative agent, but the need for the medication must be
weighed against the symptoms. Patients can sometimes be
switched to another agent with a lower risk of TD. Oddly
enough, when the dose is decreased, or the medication is discontinued, an increase in TD
symptoms may be seen. This is
due to the fact that the medication
often masks some of the symptoms
of TD. These symptoms then only
appear with a dose change.
Most cases of tardive dyskinesia are mild and some may be
reversible, but others are irreversible and can be debilitating.
Of the medications that can cause TD, antipsychotics are the
most prominent. The 2011 OSCAR data shows that 25.2%
of long-term care residents receive an antipsychotic agent.
One study that followed the development of tardive dyskinesia showed that 32% of patients had persistent tics after five
years of exposure to a causative agent, 57% after 10 years,
and 68% after 25 years. Other studies have shown that 510% of those treated with antipsychotics develop TD each
year. The data concludes that if treated long enough, almost
all patients will develop tardive dyskinesia.
Although TD was first described in 1964, the exact mechanism of action is not fully understood. The most popular
theory is that dopamine receptor blockade leads to the upregulation of receptors and hypersensitivity, especially with
Dopamine-2 (D2) receptors. Dopamine is a neurotransmitter
which is essential to CNS function. Too little stimulation of
dopamine receptors leads to abnormal nerve transmission
and muscle movement, such as in Parkinson’s disease. Typical antipsychotic agents, such as Haldol and Thorazine, block
mainly dopamine D2 receptors. The newer, atypical agents,
(Risperdal, Zyprexa, Clozaril) also block D2 receptors, but
Other treatments that have been
tried are anecdotal in success.
These include the use of vitamin E
and B6, clonidine, propranolol,
baclofen, melatonin, benzodiazepines, and botox. Antiepileptic medications such as Depakote and Keppra have
been tried along with anti-Parkinson’s medications like
Mirapex and Requip. Another agent which has had some
success is the dopamine-depleting agent, tetrabenazine
(Xenazine). This medication carries a Black Box Warning
due to increased risk of depression and suicidal thoughts.
Although clozapine (Clozaril) has been shown to reverse TD
in some cases, it carries its own risks of neutropenia. Patients, physicians, and pharmacies must be enrolled in the
clozapine REMS program. Monthly to weekly CBC monitoring must be done on patients receiving Clozaril before the
medication can be dispensed.
Prevention is the key “treatment” for tardive dyskinesia.
Residents and family members should be informed of the
risk of TD as well as the signs and symptoms to look for.
The use of medications causing TD should be restricted to
residents for which there are no other alternatives and doses
should be reviewed and reduced periodically.
Residents
should also be monitored by the nursing staff periodically
using either a DISCUS or AIMS form. These should be
completed on admission for all residents, then every 6
months for those receiving TD-causing meds, and within 3
months of a dose reduction or discontinuation.
Page 6
Neil Medical Group – Pharmacy Services Division
Article by Lori Poplin, Pharm D
Medical Calculations Quiz
by Crystal Chandler, Pharm D, CGP
Consultant Pharmacist
1. Lasix is available in 2-ml ampoules labeled as 10mg/ml. How many ampoules must be used to obtain a single 80mg dose?
A.
B.
C.
D.
2.
An expectorant contains 480mg of dextromethorphan per 6-fluid ounce bottle. How many mg of drug are present in every
teaspoonful dose?
A.
B.
C.
D.
3.
4
8
6
16
13.3 mg
14.5 mg
10 mg
15 mg
A 200 ml bottle of penicillin suspension (125mg/5ml) is dispensed for a resident with dysphagia. The directions read “ 1 tsp
every 6 hrs ATC.” How many days supply was dispensed?
A.
B.
C.
D.
7 days
12 days
14 days
10 days
4. A resident who wishes not to be hospitalized is to receive an infusion of 2 gm of lidocaine in 500mL of D5W at a rate of 2mg/
min. What is the flow rate in ml/h?
A.
B.
C.
D.
An on-call physician returned your call after receiving a sub-therapeutic phenytoin level from the lab late one Friday evening.
The physician ordered phenytoin suspension 200mg now and in the morning. Since this was ordered after-hours, the medication has to be obtained from the back-up 24 hr local pharmacy. Instructions on the label did not state how many ml of
125mg/5ml suspension to give. How many ml do you draw up for each dose of phenytoin?
A.
B.
C.
D.
Vancomycin was dosed by NMG pharmacy per physician orders. Pharmacy calculated dose as Vancomycin 750 mg IV in
250 ml NS every 36 hrs for 12 days. Solution is to be administered over at least 90 minutes. What is the calculated flow rate
in ml/hr (rounded estimated value acceptable)?
A. 250 ml/hr
B. 148.6 ml/hr (150 ml/hr)
C. 150 ml/hr
D. 166.6 ml/hr (175ml/hr)
2. A
3. D
4. B
5. C
6. D
ANSWERS
6.
6ml
7ml
8ml
10ml
1. A
5.
40 ml/h
30ml/h
60ml/h
100 ml/h
Neil Medical Group – Pharmacy Services Division
Page 7
Kinston Pharmacy
2545 Jetport Road
Kinston, NC 28504
Phone 800 735-9111
Fax 800 633-3298
Neil Medical
Group
Pharmacy Services
Mooresville Pharmacy
947 N. Main Street
Mooresville, NC 28115
Phone 800 578-6506
Fax 800 578-1672
...a note from the Editor
Working in LTC has always been challenging, but regulatory changes and
reductions in reimbursement have underscored this. Persistence and hard work
can help get us through.
“Nothing in the world can take the place of persistence. Talent will not; nothing is
more common than unsuccessful men and women with talent. Genius will not;
unrewarded genius is almost a proverb. Education will not; the world is full of
educated derelicts. Persistence and determination alone are omnipotent. The
slogan “press on” has solved and always will solve the problems of the human
race.”
Author…..Calvin Coolidge
So…..in the changing world of long term care…...and with dedication for
those we serve….keep the faith…….embrace every new challenge…….look
at every “set back” as an opportunity to grow……..and……
press on.
Sincerely,
Cathy Fuquay
Pharm Notes is a bimonthly publication by Neil Medical Group Pharmacy Services Division.
Articles from all health care disciplines pertinent to long-term care are welcome. References
for articles in Pharm Notes are available upon request. Your comments and suggestions are
appreciated. Contact:
Cathy Fuquay ([email protected])
1-800-862-4533 ext. 3489
Note: Periodically, we are asked to add a name to our distribution list. At this time, copies of
Pharm Notes newsletters are distributed in bulk to Neil Medical Group customers only.