P&T Update - University Hospital · tra smi obyc v eg ’ u hw c ou gh i nrsz , t a dk e a ti ngu s ld cop r . G enr al pc u to shdb k w tham yb sup cdofMERS, r n tr av e lsf om hA

Fourth Quarter 2015Vol. XIII, Issue 4

P&T Update

Special Points of Interest:• P&T Update-Formulary

Addition/Deletion

• Policy and Procedures Update

• HIV Guidelines Update 2015

• Optimal Treatment and Prevention for Acute Diarrhea in Children

• FDA ALERT: DPP-4 Inhibitors and their association with severe joint pain

• Students from the Rutgers University – New Jersey MedicalSchool Pre-Medical Honors Program Visit the Pharmacy

• Meet Our New DSRIP ClinicalPharmacist and Pharmacy Technicians

EDITORS:Andre Emont,Pharmacy Director

Victor Pardo,Operations Manager

Michael Chu,Clinical Pharmacy Manager

Nishat Faruqui,Clinical Pharmacist

Helen Horng,Clinical Pharmacist

Polly Jen,Clinical Pharmacist

Gregory Eilinger,Clinical Pharmacist

Merlin Punnoose,Clinical Pharmacist

Joe Hessell, Clinical Pharmacist

Formulary Addition/Deletion1. Diclofenac sodium injection (DylojectTM) – formulary addition request

Diclofenac sodium is an injectable NSAID indicated for the management of mild tomoderate pain, as well as moderate to severe pain alone or in combination withopioid analgesics. – Formulary addition of diclofenac sodium injection (DylojectTM)not deemed necessary at this time

2. Fosfomycin tromethamine (Monurol®) – formulary addition requestFosfomycin tromethamine is an oral antibiotic FDA approved for the treatment ofuncomplicated urinary tract infections (UTIs) - Formulary addition of fosfomycintromethamine (Monurol®) as restricted anti-infective approved

3. BSS® sterile irrigating solution in polypropylene bags – line extensionThe Ophthalmology Dept. requested the provision of BSS® sterile irrigating solutionin polypropylene bags, rather than the previously supplied glass bottles. Thesesolution bags will be used with the new Alcon Centurion Cataract Machines. – Line extension of BSS® sterile irrigating solution in polypropylene bags approved

4. Valganciclovir (Valcyte®) oral suspension – line extensionFormulary addition of the oral suspension formulation was requested for use inpatients where tablets cannot be used. - Line extension of valganciclovir (Valcyte®)oral suspension approved

5. Linezolid IVPB 600 mg/300 mL sodium chloride 0.9% - line extensionFormulary addition of linezolid 600 mg/300 mL sodium chloride 0.9% bags wasrequested to provide an alternate diluent for the antibiotic. - Line extension oflinezolid IVPB 600 mg/300 mL sodium chloride 0.9% approved

6. Amphotericin B liposome (Ambisome®) – formulary reinstatementFormulary reinstatement of amphotericin B liposome (Ambisome®) was requestedfollowing recent changes to the institution’s pricing for lipid formulations of theantifungal. – Formulary reinstatement of amphotericin B liposome (Ambisome®)approved

7. Amphotericin B lipid complex (Abelcet®) – formulary deletionFormulary deletion of amphotericin B lipid complex (Abelcet®) was requestedfollowing recent changes to the institution’s pricing for lipid formulations of theantifungal. – Formulary deletion of amphotericin B lipid complex (Abelcet®)approved

8. Aripiprazole (Abilify®) oral solution – manufacturer discontinued The manufacturer has voluntarily discontinued aripiprazole (Abilify®) 1 mg/mL oralsolution due to business reasons. - Formulary deletion of aripiprazole (Abilify®) oralsolution approved

9. Aripiprazole (Abilify®) 9.75 mg/1.3 mL injection – manufacturer discontinued The manufacturer has voluntarily discontinued aripiprazole (Abilify®)9.75 mg/1.3 mL injection due to business reasons. – Formulary deletion ofaripiprazole (Abilify®) 9.75 mg/ 1.3 mL injection approved

(Continued on page 2)

2

Formulary Addition/Deletion(Continued from page 1)

Policies & Procedures/Floor Stock Update1. High Risk/High Alert, Look Alike/Sound Alike

Medications policy revisionRevisions to the high risk/high alert, look alike/soundalike medications policy (#707-500- 110A) waspresented for member review and approval. – Policyrevisions approved

HIV Guidelines Update 2015As of April 8, 2015, the guidelines for the use for

antiretroviral agents in HIV-1 adults and adolescentswere updated. Before selecting which regimen touse, there are certain characteristics and conditionsthat will help decide the appropriate regimen for aspecific patient. First and foremost are the viral load

and CD4 cell count before treatment begins. Othercharacteristics like genotypic drug resistance testand HLA-B*5701 sensitivity screening for abacavircan also narrow down the choice of regimen. Anyco-morbidities, co-infections (like hepatitis C virus),medication interactions and costs can affect whichregimen to use. It is also important to remember tochoose a regimen the patient can tolerate andadhere to as well. Recommended regimens usuallycontain two NRTIs (nucleoside/nucleotide reversetranscriptase inhibitors) in combination with aboosted protease inhibitor, integrase inhibitor or anNNRTI (non-nucleoside reverse transcriptaseinhibitor).

There are currently five antiretroviral regimens touse for initial treatment in naïve patients, fourintegrase strand transfer inhibitor (INSTI) regimensand one protease inhibitor (PI) regimen. Someregimens contain a pharmacokinetic enhancer,either cobicistat or ritonavir, to improve the kineticsof the antiviral drugs. Two of the INSTI regimenscontain dolutegravir with either abacavir/lamivudine or tenofovir/emtricitabine. Dolutegravir

is usually given once daily and can be takenregardless of food. It has few drug interactions butdoes increase metformin levels and rifampin candecrease dolutegravir concentrations. Limitedreports of resistance have been noted suggestingdolutegravir has a high genetic barrier to resistance.Another INSTI regimen contains raltegravir withtenofovir/emtricitabine, which needs to beseparated from any aluminum or magnesiumantacids at least 2 hours before or 6 hours after. The last INSTI regimen is elvitegravir/cobicistat/tenofovir/emtricitabine and is appropriate forpatients with a creatinine clearance above 70ml/min.

The recommended boosted PI regimen isdarunavir, ritonavir, and tenofovir/emtricitabine. Inclinical trials, darunavir with ritonavir has shown tohave good virological efficacy and is bettertolerated than the other medications in its class.The other boosted PI regimens available areconsidered alternative regimens based on efficacy,tolerability and certain parameters like viral loadand creatinine clearance. Atazanavir-based boostedregimens are dosed daily with food and require anacid pH in the stomach for dissolution. Acidsuppressive medications, such as antacids,esomeprazole and famotidine, can hinder theabsorption of atazanavir. Both darunavir andatazanavir are also commercially available in a co-formulated product with the booster cobicistat.Atazanavir/cobicistat and tenofovir/emtricitabinecan only be used in patients with a creatinineclearance greater than 70 ml/min. Darunavir/cobicistat and tenofovir/emtricitabine also have thesame creatinine clearance cutoff.

Unfortunately, some patients may fail the initialregimen. If there is failure of a boosted PI regimen,

10. Phentolamine mesylate 5 mg injection –manufacturer discontinued Phentolamine mesylate5 mg injection is no longer commercially available.– Formulary deletion of phentolamine mesylate 5mg injection approved

(Continued on page 3)

3

it is often due to poor adherence or drug/foodinteractions. Clinical trials have shown thatmaintaining that same regimen is as effective asswitching regimens. The regimen can be continuedgiven that the patient can tolerate the side effects,stays adherent to therapy and does not havemutations against the individual drugs. Failure of anINSTI based regimen can be associated withresistance to the accompanying NRTIs. Not enoughclinical trials have been done to guide healthcareproviders on how to handle INSTI regimen failures;however, the patient may respond to boosted PIregimens.

The goal of antiretroviral therapy is to reduce themortality and morbidity from HIV and theprevention of transmission to others. Control of HIVinfection is measured by a CD4 count greater than200 cells/mm3 and an undetectable viral load. Bychoosing an appropriate regimen, antiretroviraltherapy can suppress the viral load and increase theCD4 count, improving the patient’s immunologicalresponse against opportunistic infections. References:Panel on Antiretroviral Guidelines for Adults and Adolescents.Guidelines for the use of anti- retroviral agents in HIV-1-infectedadults and adolescents. Department of Health and HumanServices. Available athttp://www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf. Accessed August 19, 2015. F1-27Contributed by:Alissa Hui, PharmD Candidate 2016, St. John’s University

(Continued on page 4)

There has been an outbreak of Middle EastRespiratory Syndrome Coronavirus (MERS-CoV) inSouth Korea with 182 confirmed cases and 33deaths in the country as of July 2015. MERS-CoV wasfirst identified in April 2012 in Saudi Arabia, and thisis the first time there has been an outbreak outsidethe middle-eastern country.1

The risk of MERS in the US is very low andgenerally coronaviruses are not thought to beserious pathogens. However, the 2002 pandemic ofSARS-CoV (Severe Acute Respiratory SyndromeCoronavirus), causing 800 confirmed deaths, hasbrought concerns about a possible similar pattern

HIV Guidelines Update 2015(Continued from page 2)

Middle East Respiratory Syndrome Outbreak in Asia -Possible Therapeutic Approaches and Role of

Healthcare Professionals

4

for MERS. Unlike SARS-CoV, which originates frombats, the MERS-CoV pathogen originates fromcamels in the Middle East countries, such as Oman,Egypt, Jordan, United Arab Emirates and SaudiArabia.1

MERS-CoV is transmissible by close contact andrespiratory secretions. MERS symptoms range fromhaving no symptoms to fever, cough, shortness ofbreath, headache, dysnpea, myalgias, nausea,vomiting and diarrhea.2 There are concerns indetecting MERS-CoV because its symptoms resembleinfluenza and laboratory tests can be (produce) falsenegatives when the sample swabs are taken fromthe upper respiratory tract.

Currently there are no treatment or prophylaxisoptions for MERS-CoV, but there are studies showinga possible target for therapy. MERS-CoV is a singlestranded RNA virus which codes for 4 proteins. TheS protein plays an important role in viral membranefusion and cell entry. The MERS-CoV S proteinsubunit, S1 binds to CD26 (DPP4) surface receptor.To inhibit viral entry, there are current studies todevelop vaccines that target the receptor bindingdomain (RBD) of S1. There are also studies to inhibitthe MERS-CoV protease.3,4 Anti-MERS-CoVConvalescent Plasma Therapy is another ongoingstudy but has yet to recruit participants. Themethod is to administer the immunoglobulin ofpreviously MERS-exposed and recovered patients toMERS-infected patients. A systematic review andmeta-analysis by University of Nottinghamconfirmed convalescent plasma therapy for MERSmay be the most promising and immediate therapyto be available for infected patients.5

Because MERS is a new viral disease, no vaccineshave been developed for clinical use, but few have

been tested to be effective in pre-clinical studies. Fornow, it is thought that prevention and supportivecare are key for management of this infection.2Preventative measures include washing hands withsoap and water for 20 seconds, or using an alcohol-based sanitizer and disinfecting frequently touchedobjects such as table surfaces and doorknobs. Otherpreventative measures would be to preventtransmission by covering one’s mouth whencoughing or sneezing, not sharing drinking andeating utensils and limit close personal contact.General precautions should be taken with patientsthat may be suspected of MERS, such as recenttravelers from the Arabian Peninsula and SouthKorea, close contacts of a traveler from the area andpatients with exposure to camels. The followingsymptoms, while general, should be consideredsuspicious: fever, coughing, shortness of breath,chills, aches, nausea and vomiting. Healthcareworkers should also follow infection controlmeasures such as maintaining hand hygiene anddonning PPE (Personal Protective Equipment) such asgloves, gowns and eye and respiratory protection.

As for supportive care, infected patients or patientsof high suspicion should be placed in an AirborneInfection Isolation Room (AIIR). If not available, theyshould be transferred to a facility with AIIR and coveredwith a facemask before arrival. Only essential personnelshould enter the AIIR and prompt communicationamong health workers is recommended. Supportivetherapy for infected patients include hydration with IVfluids, antipyretics/analgesics for fevers and respiratorysupport.2

References:1. World Health Organization (2015, July). Coronavirus

Infections. Retrieved from http://www.who.int/csr/disease/coronavirus_infections/en/.

2. Centers for Disease Control and Prevention (2015, June).Middle East Respiratory Syndrome. Retrieved fromhttp://www.cdc.gov/coronavirus/mers/.

3. Sharif-Yakan A, Kanj SS. Emergence of MERS-CoV in the MiddleEast: Origins, Transmission, Treatment and Perspectives. PLoSPathogens 2014; e1004457. Web. 14 June 2015.

4. Zhanga N, Tanga J, Lub L, et al. Receptor-binding domain-based subunit vaccines against MERS Co-V. VirusResearch. 2015; 202:151-9.

5. Arabi Yaseen M; King Abdullah International Medical ResearchCenter;Anti-MERS-COV Convalescent Plasma Therapy. In:ClinicalTrials.gov [Internet]. Bethesda (MD): National Libraryof Medicine (US). 2000- [2015]. Available from:https://clinicaltrials.gov/ct2/show/record/NCT02190799?term=MERS&rank=2: NCT02190799.

Contributed by:Soyoung (Stacy) Lee, PharmD candidate 2016, Rutgers UniversityErnest Mario School of Pharmacy

Middle East Respiratory Syndrome(Continued from page 3)

5

Optimal Treatment and Prevention for Acute Diarrhea in Children

Overview:

Diarrhea is the one of the leading causes of deathamong children under the age of 5. It accounts forapproximately 700,000 child deaths each yearworldwide—mostly due to contaminated food, watersources and poor hygiene. In modern society, fatalityfrom diarrhea can be easily avoided with propersanitation methods and access to clean water supply.However, 780 million individuals around the world stilllack the access to clean water and 2.5 billion lackimproved sanitation. It is estimated that nearly 88% ofdiarrheal deaths is due to inadequate safe water andpoor hygiene practices. Children are much more proneto severe consequences from diarrhea leading tomortality and stunting, especially those who aremalnourished and immunosuppressed. Timelymanagement and widespread awareness of itsconsequences world-wide can help to prevent furtherincrease in child mortality due to diarrhea.

Diagnosis/Treatment:

Diarrhea is defined as “the passage of three or moreloose or liquid stools per day”.1 Symptoms can last forseveral days, leading to loss of essential nutrients andsevere dehydration in children. The outcome can beeven more fatal to those children who aremalnourished or have poor immune systems, which iscommon in developing countries. Diarrhea is mostoften caused by infections from a variety of pathogensincluding bacterial, viral, or parasitic organisms and isusually transmitted via the oral-fecal route. In 2006, theUnited Nations Children’s Fund (UNICEF) and theWorld Health Organization (WHO) reported on theimportance of appropriate and prompt treatment toprevent diarrheal death in children. There has beencontinuous efforts to shed light on the importance ofinternational collaboration to reduce the mortality ratesince the 1970’s, but it was constantly overshadowedby other global emergencies.

There are 3 main types of acute childhood diarrheawhich differ in treatment: acute watery diarrhea,bloody diarrhea, and persistent diarrhea. Acute waterydiarrhea is mostly associated with cholera, which canlead to rapid fluid loss and severe dehydration.Pathogens mostly responsible for this type of diarrheaare V. cholerae, E. coli, and rotavirus. The second typeof acute diarrhea is bloody diarrhea, also termeddysentery. It is associated with significant nutrient loss

and intestinal damage. This type of diarrhea is mostcommonly caused by Shigella, a bacterial organismthat can be responsible for the most severe cases ofdiarrhea.3 The last type is persistent diarrhea, which isclassified as the type of diarrhea where symptoms lastfor at least 14 days with or without blood.

The key management in treating any acute diarrheain children is immediate fluid and nutrientreplenishment. Children suffering from diarrhea areprone to severe dehydration and malnutrition, whichcan rapidly lead to spiking mortality rates. Recentguidelines recommend oral rehydration therapy (ORT)as first line treatment, or the more advanced oralrehydration salts (ORS). The ORS mixture consists ofclean water, salt, and sugar and is absorbed in theintestines to replenish the fluids lost in the stool. Forthose suffering from critical diarrhea where a patient isseverely dehydrated or is in a shock state, the first linetreatment would be IV fluids. Unfortunately in thedeveloping countries, only 39% of children withdiarrhea receive the recommended ORT.3 For everyepisode of diarrhea, children are at higher risk ofstunted growth and development. Therefore, it iscrucial to implement a mainstay therapy and trainingprogram in communities to promptly manage andtreat these children for dehydration and malnutritionto prevent future damage.

(Continued on page 6)

(Continued on page 7)

6

nutrition replacement to prevent further complications.However, it is also important to keep in mind thatproper hygiene and sanitation go hand-in-hand alongwith treatment. It is imperative to raise awareness ondrinking safe water, washing hands properly, andpracticing good sanitation methods (such as putting astop to open defecation which is common in somecountries). By enforcing proper treatment under therecommended guidelines and promoting preventivemethods worldwide, many children’s lives can be savedand the overall mortality rate from diarrhea can bedrastically reduced.References:1. "Diarrhoeal Disease." WHO. 1 Apr. 2013. Web. 27 Aug. 2015.

<http://www.who.int/mediacentre/ factsheets/fs330/en/>. (1)2. Kotloff KL, Nataro JP, Blackwelder WC. Burden and aetiology of

diarrhoeal disease in infants and young children in developingcountries. Lancet. 2013 Jul 20;382(9888):209-22. PubMed PMID:23680352.

3. UNICEF, WHO. Diarrhoea: why children are still dying and whatcan be done. WHO. 2009. Link:http://apps.who.int/iris/bitstream/10665/44174/1/9789241598415_eng.pdf

Contributed by:Hye Jin Lee, Pharm.D Candidate 2017, Rutgers University

Vitamin A and zinc supplements are alsorecommended in order to alleviate the severity andduration of symptoms. Studies have shown a reductionin mortality by nearly 30% in children receiving thesesupplements.3 In the case of bloody diarrhea,antibiotics may be given. However, widespread usageof antibiotics is not preferred due to the possibility ofdeveloping resistance to bacterial organisms. Instead,providing immunizations for pathogens that can causediarrhea can help reduce mortality. A pathogen knownas rotavirus is responsible for approximately 40% ofhospitalizations in children due to diarrhea world-wide, leading to hundreds of thousands of deaths eachyear. Implementation of this vaccine in those countriesmost afflicted with children’s diarrhea can drasticallylower the risk of death due to diarrhea.

Overall, it is crucial to highlight the importance ofimplementing the proper guidelines in treatingchildhood diarrhea especially in the developingcountries. The first and foremost key in treatingchildren with acute diarrhea is immediate fluid and

Optimal Treatment and Prevention for AcuteDiarrhea in Children (Continued from page 5)

FDA ALERT: DPP-4 Inhibitors and their association with severe joint pain

On August 28, 2015, the U.S. Food and DrugAdministration (FDA) issued an alert regarding thedipeptidyl peptidase-4 (DPP-4) inhibitor drug class,used for treatment of type 2 diabetes mellitus(T2DM), and their association with severe jointpain. The medications included in this class arelisted in table 1.

Table 1. List of FDA-approved DPP-4 inhibitors

DPP-4 inhibitors are oral medications used in the

treatment of T2DM and work by increasing incretinlevels (more notably GLP-1 and GIP) to inhibitglucagon release, increase insulin secretion, andimprove beta-cell functioning. Since sitagliptin’sapproval in 2006, the DPP-4 drug class has provento be effective in reducing HbA1c levels by up to1% when used in combination with diet and

exercise.

The FDA alert involving the DPP-4 class comes after a search ofthe FDA Adverse Event ReportingSystem (FAERS) database yielded33 cases of severe arthralgia(joint pain) linked to thesemedications from October 16,2006 through December 31,2013. Of these 33 cases, mostlypatient-reported, 28 involvedsitagliptin. This finding mirrors

DDP-4 Inhibitors Combination Products

sitagliptin (Januvia®) sitagliptin/metformin (Janumet®)

sitagliptin/metformin ER (Janumet XR®)

saxagliptin (Onglyza®) saxagliptin/metformin ER (Kombiglyze XR®)

linagliptin (Tradjenta®) linagliptin/empagliflozin (Glyxambi®)

linagliptin/metformin (Jentadueto®)

alogliptin (Nesina®) alogliptin/metformin (Kazano®)

alogliptin/pioglitazone (Oseni®)

7

PDA ALERT: DPP-4 (Continued from page 6)

the fact that sitagliptin accounts for more than 80%of DPP-4 prescriptions by healthcare providers.

The reports of severe arthralgia occurred anywherefrom 1 day to years after starting DPP-4 medicationtherapy. Once therapy was discontinued, thearthralgia subsided within a month; when providersattempted to reinitiate therapy, some patientsdeveloped the same severe joint pain again.

Both patients and healthcare providers are urged toreport any future cases involving DPP-4 inhibitorsand arthralgia to the FDA MedWatch Program. It isnot necessary to discontinue use of DPP-4 inhibitorsin patients already stable on their medication. If apatient experiences arthralgia while on a DPP-4inhibitor, it is recommended to discontinue therapy

and initiate treatment with another drug class thatis FDA approved for T2DM. All package inserts forDPP-4 inhibitors have been updated to include thisrecent FDA alert.References:FDA. (2015, August 28). FDA drug safety communication: FDAwarns that DPP-4 inhibitors for type 2 diabetes may cause severejoint pain. Retrieved fromhttp://www.fda.gov/downloads/Drugs/DrugSafety/UCM460038.pdfJanuvia® [package insert]. Whitehouse Station, NJ; Merck andCo., Inc.; 2010American Diabetes Association. 2015, January. Standards ofMedical Care in Diabetes. Retrieved from http://diabetes.teithe.gr/UsersFiles/entypa/STANDARDS OF MEDICALCARE IN DIABETES 2015.pdf

Contributed by:Freddy G. Mejia, Pharm.D Candidate 2016, Rutgers UniversityReferences

Newark High School Students from the Rutgers University-New Jersey Medical School Pre-Medical Honors

Program Visit the Pharmacy

Every so often, high school students from the Pre-Medical Honors Program at Rutgers University-NewJersey Medical School get the chance to visitmultiple sites of University Hospital to betterunderstand how different healthcare professionalscontribute to the multidisciplinary care of patients.Once weekly, students attend lectures andparticipate in interactive sessions alongside mentorscurrently in the medical school.

The most recent visit was on October 7th, where20 students were able to visit the pharmacy to learn

more about the overall responsibilitiespharmacists have and the challenges they faceon a day-to-day basis. With the help of Dr.Gregory Eilinger (IRB Pharmacist) and FreddyMejia (Pharmacy Student), the students wereable to experience how each part of thepharmacy runs. A brief talk was given on theeducational and licensing requirements forpharmacists, what roles a pharmacist has inhealthcare, and the multiple areas of practiceavailable for work as a Doctor of Pharmacy(Pharm.D).

The most notable reaction from thestudents was when they got to see themedical leeches stored in the pharmacy,

although some kept their distance! The studentswere engaged throughout their visit and askedmeaningful questions, to help them decide if beinga pharmacist was right for them. The pharmacyalways welcomes students from the Pre-MedicalHonors Program to help promote pharmacyawareness and encourages students to consider acareer in pharmacy.

Contributed by:Freddy Mejia, Pharm.D Candidate 2016, Rutgers University

Welcome New Clinical Pharmacist

8

Joe Hessell, Pharm. D., BCPS -DSRIP Clinical PharmacistDr. Hessell received his Doctor of Pharmacy degree from Ernest Mario School of Pharmacy at

Rutgers University in 2012. He then completed a PGY-1 pharmacy practice residency at SaintMichael’s Medical Center in Newark, NJ, where he continued to work as a clinical pharmacistspecializing in infectious diseases for 2 years. Seeking an opportunity involving more direct patientcare, he found the DSRIP pharmacist position of the Healthy Heart program to be an excitingopportunity. He is honored to become a member of the UH Pharmacy and Ambulatory CareCenter. Outside of work, he enjoys playing music, snowboarding, rock climbing, and traveling.

Mr. Shirish Shukla, RPh hasbeen an asset to thepharmacy department for 15years. He is knowledgeable,energetic, kind, sees the bestin everyone and has thebiggest heart. Always curious

to learn, he had three times the continuing educationneeded in any license renewal period. He made our daya lot better by his presence. Even though he hadreached the age of retirement, Mr. Shirish was one ofthe “sharpest knives in the drawer”. His intelligence,energy, and zeal are all way above average. It is actuallyquite difficult to keep up with this senior citizen! Evenat the gym, Mr. Shirish moves faster than a speeding

bullet, keeping up with the teenagers there. He is aforce to be reckoned with.When one decides to retire, the general rule of

thumb is to treat the person retiring–not Mr. Shirish, hetreated all three shifts and some nursing departmentsin other areas like chemotherapy. This was with foodordered from the local restaurant. It happened thatsomebody mentioned that they missed his Indian foodand for that Mr. Shukla’s wife made an Indian spreadthat filled the long conference room table and mindyou, this was after his retirement!!!! He is a wonderfulperson who is missed every day. We enjoyed workingwith him, and we have his standards to try to keep upwith now. Thanks to Mr. Shirish, none of us will let oldage slow us down.

Cerry has been working as a pharmacy technician since 2012. She enjoys doingpharmacy work and learning new things about it. She loves to help and serve other peopleespecially those who are in need. She likes to sing and dance. She works hard for all thethings she wants. She believes in the saying “If you can dream it, you can do it.”

Welcome New Pharmacy Technician

Happy Retirement Mr. Shirish