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The new initiative is a way for NCPA to proactively engage its network of community pharmacies during a potential public health crisis.

NCPA's New Consortium Exemplifies Preparedness in Community Pharmacy

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Kurt Proctor currently serves as the President of the Innovation Center at the National Community Pharmacists Association (NCPA) as well as Senior Vice President of Strategic Initiatives. He's been in the pharmacy industry since 1989 and has been a key leader with the NCPA since 2013.

Kurt Proctor, PhD, RPh, President of the NCPA Innovation Center, discussed his organization’s efforts in launching the Independent Community Pharmacy Consortium for Government Engagement.

Q&A: NCPA Announces Independent Community Pharmacy Consortium for Government Engagement

journal explores issues within pharmacy, from the impact advocacy can have in community pharmacies to staffing shortages across multiple sectors within pharmacy. This month’s issue also explored the importance of disease awareness months and how they are opportunities to maximize valued care. Check out a preview of this month’s issue here.

download the PDF of the Total Pharmacy August 2024 issue here

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See what’s trending in pharmacy with a preview of the Total Pharmacy August issue.

Total Pharmacy

In This Issue: Total Pharmacy August 2024

Combining sodium glucose co-transporter 2 inhibitors (SGLT2is) with glucagon-like peptide-1 receptor agonists (GLP-1RAs) may offer additional protection against cardiovascular and kidney disease in patients with type 2 diabetes (T2D), according to the results of a new meta-analysis published in 

 and presented at the 61st European Renal Association Congress in Stockholm, Sweden.

Separately, SGLT2is and GLP-1RAs have demonstrated cardiovascular benefits. However, little clinical literature has focused on outcomes associated with using the medicines together. Due to the growing prevalence of GLP-1RAs in the 

 and obesity landscape, accelerated by an increasing number of indications for the agent class, this is a crucial area for further study.

The SGLT2 Inhibitor Meta-analysis Cardio-Renal Trialists’ Consortium (SMART-C) is the largest assessment of outcomes for the combined therapeutic use of SGLT2is and GLP-1RAs. The study gathered data from 12 large-scale, placebo-controlled trials of SGLT2is involving 73,238 patients with diabetes. Of these, 3065 were already receiving GLP-1RAs.

Overall, SGLT2is lowered the risk of major adverse cardiovascular events by 11% and hospitalization for heart failure or cardiovascular death by 23% compared to placebo. Notably, this benefit was seen regardless of whether patients were also taking GLP-1RAs.

When used together with GLP-1RAs, SGLT2is reduced the risk of chronic kidney disease progression by 33% and slowed the annual loss of kidney function by nearly 60%.

The study found no additional safety concerns when SGLT2is were used in combination with GLP-1RAs.

Study Reveals Robust Benefits of Semaglutide in Protecting Against Kidney, CV Events in Patients With T2D

Current meta-analysis results build off positive results of the landmark FLOW trial (

). Published earlier in May, results of the international, double-blind, randomized, placebo-controlled phase 3 trial spotlighted semaglutide’s effectiveness in lowering the risk of kidney failure, decelerating worsening kidney function, and protecting against the risk of cardiovascular events and death, in patients with T2D.

“SGLT2 inhibitors have clear protective effects against heart failure and chronic kidney disease, while GLP-1 receptor agonists can reduce the risk of heart attack, stroke, and also kidney disease—as recently demonstrated in the landmark FLOW trial,” said Brendon Neuen, lead author, clinical associate professor, senior research fellow at The George Institute for Global Health, and director of kidney trials at Sydney’s Royal North Shore Hospital, in a news release.

 “Our findings support using this combination to further improve outcomes in patients with type 2 diabetes who meet guideline recommendations for both therapies.”

Elevated glucose from diabetes can damage blood vessels in the heart and kidneys, increasing the risk of 

 and kidney disease. In fact, diabetes is the most common cause of chronic kidney disease.

Moreover, estimates predicting that T2D prevalence will more than double in the next 30 years, surpassing 1 billion global cases by 2050, further strengthen the need for research into diabetes care.

 According to Neuen in an interview with 

 conducted over email, the current study offers valuable insights for developing global treatment strategies for the condition.

"These findings, which represent the largest and most comprehensive evaluation of the combined use of SGLT2i and GLP-1RA, provides the clearest evidence yet that combined use of both medicines can further reduce cardiovascular and kidney disease," said Neuen. "We anticipate that these findings will inform how people with diabetes are treated worldwide, including influencing major clinical practice guidelines.

Although current results suggest that using SGLT2is and GLP-1RAs in tandem may offer robust protection against cardiovascular and kidney disease, further research is needed to fully understand the long-term effects of the combination therapy.

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1. Apperloo E, Neuen BL et al. Efficacy and safety of sodium glucose co-transporter 2 inhibitors with and without glucagon-like peptide-1 receptor agonists: A SMART-C collaborative meta-analysis of randomised controlled trials. 

. 2024. doi: 10.1016/S2213-8587(24)00183-9

2. Massaro L. Study reveals robust benefits of semaglutide in protecting against kidney, CV events in patients with T2D. 

https://www.drugtopics.com/view/study-reveals-robust-benefits-of-semaglutide-in-protecting-against-kidney-cv-events-in-patients-with-t2d

3. Combining popular diabetes drugs offers complementary heart and kidney benefits. News release. The George Institute for Global Health. July 9, 2024. Accessed July 10, 2024. 

https://www.georgeinstitute.org/media-releases/combining-popular-diabetes-drugs-offers-complementary-heart-and-kidney-benefits

4. Mayo Clinic Staff. Chronic kidney disease. Fact sheet. Accessed July 8, 2024. 

https://www.mayoclinic.org/diseases-conditions/chronic-kidney-disease/symptoms-causes/syc-20354521

5. Klein HE. Diabetes prevalence expected to double globally by 2050. 

https://www.ajmc.com/view/diabetes-prevalence-expected-to-double-globally-by-2050

When used together, sodium glucose co-transporter 2 inhibitors (SGLT2is) and glucagon-like peptide-1 receptor agonists (GLP-1RAs) were able to lower the risk of major adverse cardiovascular events and kidney disease by 11% and 33%, respectively.

Clinical

SGLT2i, GLP-1RA Combination Therapy Offers Robust Protection Against Cardiovascular, Kidney Disease

Stemming from lessons learned during the COVID-19 pandemic, the National Community Pharmacists Association (NCPA) announced on Thursday the formation of the Independent Community Pharmacy Consortium for Government Engagement—a network designed to engage community pharmacies and other pertinent drug supply chain entities during future public health emergencies.

“[The Consortium] is bringing together pharmacy services administrative organizations, wholesale distributors, and pharmacy management system vendors to streamline the engagement of community pharmacies in public health initiatives,” read an NCPA news release. “Building on the vital role played during the COVID-19 pandemic, independent community pharmacies across the United States are taking proactive steps to enhance their readiness for future public health emergencies.”

Kurt Proctor, PhD, RPh, President of the Innovation Center and Senior Vice President of Strategic Initiatives at NCPA, recently joined 

“It's an effort to make it easier to include independents because that could be challenging,” he told us. “It could be challenging for those who don't understand how independents are organized and aggregated, and who serves them for what functions, etc. It's meant to be a one-stop-shop for engaging independents.”

Read on to learn more about the NCPA’s Independent Community Pharmacy Consortium for Government Engagement. Also, stay tuned for a full-length podcast version of our conversation with Proctor, touching on several themes highlighted by the NCPA Innovation Center’s brand-new initiative.

Community Pharmacy’s Future Hangs on Advocacy, Support From All Healthcare Professionals

: Can you start by discussing what the consortium is and how it came to be?

We worked with a number of entities as we went through the COVID-19 pandemic, and lots of them worked with each other and helped each other as we went through it. If you go back to the beginning, we learned quickly that we needed to help make including independents easier for government entities. They could call a chain and get whatever stores they have, but it's a different type of entity to engage the independents. As the experience came out of that, we spent a lot of time educating the government about independents—how they're aggregated, how they contract, etc—as we got into the pandemic. As we were winding down in the pandemic, we said, “Okay, we need to be even better prepared as we go forward to meet the needs of the public, independent community pharmacies’ customers, and the communities that they serve.” Therefore, we have to take yet another step forward in making it easy to do business with independents and easy for government entities to include independents in their response. I think independent pharmacies really proved to many that they reach very important populations and that they're a very integral part of an overall response to [an] emergency situation.

In the pandemic, we [didn’t] know what the next response [needed] to be. We started out the pandemic needing to contract and needing to figure out how we're going to engage. The federal government was putting together a federal retail pharmacy partner program. They had contracts that were written for chains and they weren't written for independents or aggregators of independents. We had to kind of educate them about what that was like, what these entities are like, what it takes to engage them, and what relationships exist between aggregators and independent pharmacies. We got over that hump and we [we're] doing the vaccinations. Then, all of a sudden, we had free masks to distribute. It became not a contracting issue as much as it was a physical distribution issue. We went beyond the partners that were in the federal partnership program, certainly included them, but we got the 6 regional wholesalers involved in distributing the free masks and connected them with the strategic national stockpile and arranged for those certain pharmacies who are served by those 6 regional wholesalers to participate and be able to reach their pharmacies and their pharmacies’ customers. Again, it's an effort to make it easier to include independents because that could be challenging. It could be challenging for those who don't understand how independents are organized and aggregated, and who serves them for what functions, etc. It's meant to be a one-stop-shop for engaging independents.

: Aside from the pandemic and independent pharmacies shining as a valuable resource for public health, is there another factor or event that spurred a need for this consortium?

No, I don't think so. Not anything specific. We go back in history to other pandemics, other responses, but it was really this one. One of the events that caught our attention quite strongly was, at the beginning of the pandemic, seeing just the big change represented in the White House Rose Garden ceremony. [We were] saying, “Okay, how are they not engaging independents in this?” Because, especially with the populations that they were most concerned about reaching, that's who our members and independent pharmacies serve to a great degree. It was that visualization from the rose garden that said, along with the others who were represented there from the big-box chains, we need to make sure that we have a way for government entities to engage independents more easily in mass.

The entities that were involved in the Federal Retail Pharmacy Partnership Program cooperated with each other quite a bit in terms of sharing things and talking about “How are you handling this? How are you doing that”—all for the good of the country and the good of the patients that we're serving. I think it demonstrated that there were times and there were topics where it made sense to work together and it made sense to put a common, singular face on independents. We also learned that it's tough to get folks who don't deal with pharmacies all the time to understand independents and understand how they're aggregated. There's such a big learning curve. Folks that had just incredibly large sets of responsibility, we would explain the same thing to them multiple, multiple times. You can't necessarily expect them to remember it all. So, [we’re] putting ourselves out there as the experts about how community pharmacies are organized, who they're affiliated with, how they're aggregated, so that the government doesn't have to try to understand that, because they never will, frankly. [It’s] just [letting] them know that here we are as the easy button again for independents.

: With its focus on bolstering public health, who would you say will benefit most from the consortium’s efforts? Would you say it’s patients, community pharmacies, NCPA partners, or just public health initiatives in general?

Well, we're not trying to replace anything that exists and that functions well today, in terms of the relationship between pharmacies, the business partners they have, and the folks who you can think of them being aggregated by. It's more to be there and to be ready when something happens and somebody needs to engage independents broadly. Again, we’re the easy button for them to do that. At this point, we don't have specific initiatives of our own to undertake other than readiness and making sure that, if the call comes, that we are able to respond to it, that we're able to engage the right people. Depending on what the need is—whether it's contracting, distribution, or dissemination of education and information—all of those things we can facilitate quite easily with a solid understanding of who the players are and how this marketplace works.

McKesson Amplify Initiative Secures Funding for State Pharmacy Associations

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Independent pharmacy partners form new consortium to bolster public health emergency preparedness and response. News Release. NCPA. January 16, 2025. Accessed January 21, 2025. 

https://ncpa.org/newsroom/news-releases/2025/01/16/ncpa-independent-pharmacy-partners-form-new-consortium-bolster

Testosterone replacement therapy Azmiro is now available in the United States for use in male patients who have conditions that are associated with a deficiency or absence of endogenous testosterone, Azurity Pharmaceuticals announced in a release.

The therapy is the first and only prefilled testosterone cypionate injection approved by the FDA.

Azmiro comes as a 200 mg/mL single dose syringe and is intended for intramuscular use. This prefilled option provides greater accuracy and safety by reducing the potential for inadvertent needle sticks and exposure to products while drawing from a vial, as well as a reduced risk of microbial contamination. The safety and efficacy of Azmiro has not been established in men with age-related hypogonadism.

Patient Trust, Active Listening Key to Enhancing Men's Health Care

“Azurity’s purpose is to serve overlooked patients by developing innovative dose forms and formulations to serve unmet needs,” Richard Blackburn, CEO of Azurity, said in a release.

 “The commercial availability of Azmiro offers a convenient prefilled option for healthcare providers administering testosterone to patients.”

Testosterone deficiency, also known as hypogonadism, impacts between 20% to 50% of males in the US.

 The condition increases with age, with a particular rise in men aged 45 to 50 years. Low testosterone can also be caused by some conditions, including Klinefelter syndrome, mumps orchitis, and undescended testicles. Testosterone deficiency can lead to low energy, depression, poor concentration, low libido, and erectile dysfunction.

Testosterone replacement therapy has shown to improve the symptoms of hypogonadism and overall quality of life in patients with low serum testosterone.

 Research has shown that it can improve sexual function, bone density, muscle mass, body composition, mood, erythropoiesis, and cognition. Although testosterone replacement therapy does come with a potential risk for adverse events, it remains a safe and beneficial options for patients.

Pharmacy practice is always changing. Stay ahead of the curve: Sign up for our

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1. AZURITY PHARMACEUTICALS, INC. ANNOUNCES AVAILABILITY OFAZMIRO™ (testosterone cypionate) injection for intramuscular use, CIII. News Release. Azurity. December 11, 2024. Accessed January 15, 2025. 

https://azurity.com/azurity-pharmaceuticals-inc-announces-availability-of-azmiro-testosterone-cypionate-injection-for-intramuscular-use-ciii/

Li Y, Liu M, Cui Y, et al. Increased risk of testosterone deficiency is associated with the systemic immune-inflammation index: a population-based cohort study. 

 (Lausanne). 2022 Aug 16;13:974773. doi: 10.3389/fendo.2022.974773. PMID: 36051392; PMCID: PMC9424499

3. Anaissie J, DeLay KJ, Wang W, et al. Testosterone deficiency in adults and corresponding treatment patterns across the globe. 

. 2017 Apr;6(2):183-191. doi: 10.21037/tau.2016.11.16. PMID: 28540225; PMCID: PMC5422691.

Testosterone Replacement Therapy Azmiro Now Available in US

Although opioids are highly effective for chronic pain, they pose significant risks of misuse, addiction, and adverse effects. Nonopioid and nonpharmacologic therapies, which are at least as effective as opioids in managing pain for a variety of conditions,

 offer safer alternatives. In response to the opioid crisis, pharmacists are increasingly advocating for nonopioid strategies to optimize pain management and minimize risks. Sometimes, these can be as simple as managing mood disorders, improving sleep hygiene, or providing empathetic patient counseling.

Melissa Durham, PharmD, MACM, brings a wealth of experience in managing chronic, non-oncologic pain. As an associate professor of clinical pharmacy and associate dean at the USC School of Pharmacy and Pharmaceutical Sciences, and a clinical pharmacist at the USC Pain Center, Durham has been at the forefront of patient care for over a decade.

By understanding the complexities of pain management and the potential benefits of nonopioid interventions, pharmacists can empower patients to make informed decisions about their treatment options. In her interview with 

, Durham shared insights on how to counsel patients who might be reluctant to discontinue opioid therapy, the value of multimodal therapy, innovations in the nonopioid landscape, and more.

 What are the most common nonopioid pain management strategies that pharmacists are currently implementing in their practice?

: Multimodal therapy is critical when it comes to pain management. We know this is the gold standard, using medications that work synergistically together. So, depending on the disease state and the disease process, you might choose a variety of different medications with different mechanisms, everything from antidepressants such as tricyclic antidepressants [TCAS] and serotonin and norepinephrine reuptake inhibitors [SNRIs] to anti-epileptic drugs like gabapentin or pregabalin, anti-inflammatory drugs, and even [adding] simple analgesics like acetaminophen [to] the mix is helpful.

Some of the more out-of-the-box things that we've been working with over the last several years are agents like ketamine, which is an n-methyl-d-aspartate [NMDA] receptor antagonist that we've been able to use pretty successfully to get opioid doses down as we taper people off. Other out-of-the-box therapies, like low dose naltrexone, are more expensive and cost prohibitive because they need to be compounded. But those are a few of the nonopioid things in our toolbox that we reach to, in addition to topicals, which can be helpful in taking the edge off, but those are some of the top ones that come to mind.

And then, of course, there's non-pharmacologic therapies. It’s not just the multimodal therapy, but it's also [taking a] multi-disciplinary approach, using physical therapy, occupational therapy, pain psychology, making sure patients' mood disorders are under control as well as sleep is under control, [that’s] another important part of it too in managing pain.

 How can pharmacists effectively educate patients about nonopioid pain management options and what challenges do they face in communicating this information to patients who may be hesitant to try alternative therapies?

 This is a big challenge, especially in my patient population. I have a lot of patients who are still on opioids [and] who have been on opioids for a very long time. It can be a bit of a hard sell to broach the subject about tapering when the medications that they've been on are viewed as enabling [them] to take part in their life the way that they want to, whether it be with work, social activities, intimate activities, things like that.

So, the way that I do it is that I say [to them], “Listen, you've been on this medication for a long time. It's probably not necessarily working the way that we hoped it [would], you've probably built up a tolerance to it.”

Taking the angle around tolerance is a good way to start talking to them about how opioids can potentially predispose them to developing chronic pain, because—I don't say this to the patient—they cause neural inflammation. They activate our toll-like receptors and our glial cells, and we know that that is bad for patients’ long term, especially if they have neuropathic type pain or mixed type pain.

I’ll tell them, “You know, opioids can actually maybe even worsen your chronic pain.” I often say, “You might feel better as we take you down,” because a lot of times they do, “[and] we're going to add these other therapies so that way we can bring down your dose. Overall, it's going to allow you to have less side effects from the opioids and you might feel a cloud lifting. You might feel more energy. You might feel better,” because I've seen that a lot. Bringing [up] experiences with real-life patients that we've had success with is another really good way to do it, too.

Saying that these other nonopioid therapies are tools that we can use to optimize their pain management [is helpful]. Just like I mentioned before, how using multimodal therapy is the gold standard, I counsel a lot on [how] combination therapy and working synergistically [together] really does help from all angles of their pain management.

 What role can pharmacists play in collaborating with other health care providers to develop comprehensive pain management plans that minimize the use of opioids?

Melissa Durham, PharmD, MACM, reveals how pharmacists are uniquely positioned to counsel patients on nonopioid pain management. 

Kurt Proctor, PhD, RPh

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