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5/21/2019 Caution: Contents Under Pressure Identifying DrugInduced Hypertension Melanie Claborn, Pharm.D., BCACP Assistant Professor of Pharmacy Practice Southwestern Oklahoma State University College of Pharmacy Clinical Pharmacy

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Caution: Contents Under Pressure Identifying Drug‐Induced Hypertension

Melanie Claborn, Pharm.D., BCACP Assistant Professor of Pharmacy Practice Southwestern Oklahoma State University College of Pharmacy Clinical Pharmacy Specialist‐Oklahoma City Indian Clinic Oklahoma City, OK

1

Disclosure

  • Under guidelines established by the Accreditation

Council for Pharmacy Education, disclosure must be made regarding financial relationships with commercial interests within the last 12 months.

  • I have no relevant financial relationships or

affiliations with commercial interests to disclose.

2

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Learning Objectives

At the completion of this activity, pharmacists will be able to:

  • Describe the complications of untreated

hypertension

  • List drugs/supplements associated with

secondary hypertension

3

Pre‐Assessment Question:

What is the leading cause of death in the United States?

  • a. Heart disease
  • b. Cancer
  • c. Accidents
  • d. Influenza

4

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Pre‐Assessment Question:

A patient has blood pressure readings in the clinic that are consistently 136/82. How would you classify his blood pressure?

  • a. Normal
  • b. Elevated
  • c. Stage 1 HTN
  • d. Stage 2 HTN

5

Pre‐Assessment Question: Which of these medications can be associated with increasing blood pressure?

  • a. Cyclosporine
  • b. Erythropoietin
  • c. Indomethacin
  • d. All of the above

6

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Why talk about the same old thing…

7 Image: https://hochomecare.wordpress.com/

Nearly half of all adults in the US have cardiovascular disease

8

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Prevalence of cardiovascular disease in adults ≥20 years of age (NHANES, 2013–2016)

Benjamin EJ. Heart Disease and Stroke Statistics—2019 Update Circulation. 2019;139:e56–e528

Dishonorable Awards

Heart disease is the leading cause of death in the US Ischemic heart disease and stroke lead worldwide

10 https://www.cdc.gov/nchs/fastats/leading‐causes‐of‐death.htm Image: http://clipart‐library.com/medal‐cliparts.html

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CVD and other major causes of death for American Indians or Alaska Natives United States, 2016

Benjamin EJ. Heart Disease and Stroke Statistics—2019 Update Circulation. 2019;139:e56–e528

Heart Failure, 9.3% Stroke, 16.9% High Blood Pressure, 9.8% Diseases of the Arteries, 3.0% Other, 17.7% Coronary Heart Disease, 43.2%

Percentage of Deaths Attributable to Cardiovascular Disease (United States: 2016)

Adapted from Benjamin EJ. Heart Disease and Stroke Statistics—2019 Update Circulation. 2019;139:e56–e528 12

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CVD Risk Factors

Hypertension Cigarette smoking Overweight/ Obesity Physical inactivity Dyslipidemia Diabetes Mellitus Microalbuminuria (or GFR < 60 mL/min) Age Family History of Premature CVD

13 Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (2003). (NIH Publication No. 03– 5233). Bethesda, MD: U.S. Department of Health and Human Services.http://www.highbloodpressureinfo.org

Snapshot of Hypertension in the US

14

Images: https://healthmetrics.heart.org/heart‐disease‐and‐stroke‐statistics‐2019‐ infographic/ Accessed May 2, 2019.

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Prevalence of hypertension in adults ≥20 years

  • f age by sex and age (NHANES, 2013–2016

Benjamin EJ. Heart Disease and Stroke Statistics—2019 Update Circulation. 2019;139:e56–e528

NHANES 1976‐1980 NHANES 1988‐ 1991 NHANES 1991‐ 1994 NHANES 1999‐ 2000 NHANES 2007‐ 2012 Aware 51% 73% 68% 70% 83% Treated 31% 55% 54% 59% 77% Controlled 10% 29% 27% 34% 54%

BP Control in the US

†SBP <140 mm Hg and DBP <90 mm Hg.

  • Age 18 to 74 years with SBP 140 mm Hg or DBP 90 mm Hg or taking antihypertensive medication.

JNC VI. Arch Intern Med. 1997;157:2413‐46. JNC VII. JAMA 2003; 289:2560‐2572

16

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Extent of awareness, treatment, and control of high blood pressure by age NHANES, 2013–2016

Benjamin EJ. Heart Disease and Stroke Statistics—2019 Update Circulation. 2019;139:e56–e528

Why Blood Pressure Control Matters

18 https://healthmetrics.heart.org/heart‐disease‐and‐stroke‐statistics‐2019‐infographic/

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Target Organ Damage

19

Hypertension

Reducing average population systolic blood pressure by only 12‐13 mmHg could reduce:

20

37%

Stroke Death from all causes Death from cardiovascular cause Coronary heart disease

21% 25% 13%

  • CDC. http://www.cdc.gov/bloodpressure/infographic.htm Ogden LG, et al. Hypertension 2000; 35: 539‐543.

Chobanian, A. V. et al. Hypertension 2003;42:1206‐1252; Hebert. Archives Int Med 1993: Moser. Am Coll Cardiol 1996

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Categories of Blood Pressure in Adults

BP Category SBP DBP Normal <120 mm Hg AND <80 mm Hg Elevated 120‐129 mm Hg AND <80 mm Hg Hypertension Stage 1 130–139 mm Hg OR 80–89 mm Hg Stage 2 ≥140 mm Hg OR ≥90 mm Hg

21

*Individuals with SBP and DBP in 2 categories should be designated to the higher BP category

Whelton PK, Hypertension. 2018;71(19):e127–248 22 HBP Guideline Tool: Updated Classification and Management of High Blood Pressure in Adults https://www.acc.org/education‐ and‐meetings/image‐and‐slide‐gallery/media‐detail?id=B5A2641BE66A48C89E18066B137DE3E0

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Blood Pressure Goals

JNC 7 (2003) JNC 8 (2014) ASH/ESH (2013) ACC/AHA 2017 Uncomplicated HTN <140/90 <140/90 <140/90 <130/80 Diabetes <130/80 <140/90 <140/90 <130/80 CVD <140/90 ‐‐ <140/90 <130/80 CKD <130/80 <140/90 <140/90 <130/80 Elderly Not specified <140/90 <150/90 (≥60 years) <150/90 (≥80 years) <130 (SBP)

23 JNC 8: JAMA. 2014;311(5):507‐520,; Whelton PK, Hypertension. 2018;71(19):e127–248. 24 http://www.cdc.gov/bloodpressure/infographic.htm

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Nonpharmacological Interventions for Prevention and Treatment of Hypertension

Recommendation Approximate Impact on SBP Hypertension Weight loss Best goal is ideal body weight. Expect about 1 mm Hg for every 1‐kg reduction in body weight. ‐5 mm Hg Healthy diet Consume a diet rich in fruits, vegetables, whole grains, and low‐fat dairy products, with reduced content of saturated and total fat. ‐11 mm Hg Reduced intake of dietary sodium Optimal goal is <1500 mg/d, but aim for at least a 1000‐ mg/d reduction in most adults. ‐5/6 mm Hg Enhanced intake of dietary potassium Aim for 3500–5000 mg/d, preferably by consumption of a diet rich in potassium. ‐4/5 mm Hg Physical activity (aerobic) (dynamic resistance)

  • 90–150 min/wk
  • 65%–75% heart rate reserve

‐5/8 mm Hg

  • 90–150 min/wk
  • 50%–80% 1 rep maximum
  • 6 exercises, 3 sets/exercise, 10 repetitions/set

‐4 mm Hg Moderation of alcohol intake In individuals who drink alcohol, reduce alcohol to:

  • Men: ≤2 drinks daily; Women: ≤1 drink daily

‐4 mm Hg

Whelton PK, Hypertension. 2018;71(19):e127–248

Screening for Secondary Hypertension

26 Whelton PK, Hypertension. 2018;71(19):e127–248.

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  • Accuracy
  • Apnea
  • Aldosteronism

A

  • Bruits (renovascular disease)
  • Bad kidneys

B

  • Catecholamines
  • Coarctation
  • Cushing’s syndrome

C

  • DRUGS
  • Diet

D

  • Erythropoietin
  • Endocrine disorders

E

27

Identifiable Causes of Hypertension

Onusko E. Am Fam Physician. 2003 Jan 1;67(1):67‐74.

Secondary Causes

28

  • 1‐2%

Renal parenchymal disease

  • 5‐34%

Renovascular disease

  • 8‐20%

Primary aldosteronism

  • 25‐50%

Obstructive sleep apnea

  • Less than 1%

Pheochromocytoma, Cushings, Thyroid, Aortic coarctation, Hyperparathyroism, Adrenal hyperplasia, Acromegaly

Whelton PK, Hypertension. 2018;71(19):e127–248.

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Accuracy of Blood Pressure Measurement

  • Equipment inspected
  • Trained operator
  • Patient properly positioned
  • Caffeine, exercise, and

smoking should be avoided for at least 30 minutes before

  • Appropriately sized cuff
  • Two measurements

29

Definition of Drug‐Induced Hypertension

High blood pressure caused by a response to using, or stopping the use of, a chemical substance, drug, or medication.

– U.S. National Library of Medicine/National Institutes of Health

30 http://www.nlm.nih.gov/medlineplus/ency/article/000155.htm

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Image: http://millionhearts.hhs.gov /Docs/BP_Toolkit/TipSheet_HCP_MedAdherence.pdf 31

Risk Factors for Drug‐induced Hypertension

  • History of elevated blood

pressure

  • Decreased GFR
  • Metabolic syndrome
  • Advanced age
  • Persistent use

32 Image: http://www.clipartpanda.com/clipart_images/american‐indian‐elder‐70241502

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Drugs Associated with Increases in BP

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Amphetamines Bevacizumab Buspirone Caffeine Cocaine Corticosteroids Cyclosporine Erythropoietin Stimulating Agents Estrogen‐ containing oral contraceptives Herbals Licorice Monoamine Oxidase Inhibitors NSAIDS Phenylephrine/ Pseudoephedrine Protease Inhibitors Sibutramine (off market) Sorafenib/ Sunitinib Tacrolimus Venlafaxine

Mechanism for Increasing BP

34

  • Glucocorticoids/mineralocorticoids
  • Hormones
  • NSAIDS

Volume retention

  • Decongestants
  • Stimulants

Activation of the sympathetic nervous system

  • Cyclosporine
  • Tacrolimus

Direct vasoconstriction

  • Erythropoietin
  • Alcohol
  • VEGF

Combined Unknown

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Steroids/Glucocorticoids

  • Occurs in at least 20% of patients

– More in elderly and with family history

  • Dose dependent
  • Oral cortisol doses of 80‐200 mg/day can

increase systolic BP up to 15 mmHg in 24 hours

– At low doses cortisol has less effect

  • Cessation usually results in normalization of BP
  • Management

– Use short term or non‐systemic options – Consider diuretic if long term therapy needed

35 Grossman E, Am J Med. 2012 Jan;125(1):14‐22. Gyamlani G. South Med J. 2007 Jul;100(7):692‐9. Whelton PK, Hypertension. 2018;71(19):e127–248. Whelton PK, Hypertension. 2018;71(19):e127–24

Licorice

  • Main ingredient‐

glycyrrhizic acid

  • Excess mineralocorticoid
  • Dose dependent
  • Can have a sustained

increase in BP

36 Grossman E, Am J Med. 2012 Jan;125(1):14‐22. Image: http://www.candyfavorites.com/candy‐flavors/black‐licorice

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Estrogens (Oral Contraceptives)

  • Oral contraceptives induce HTN in ~5% of users

– 50 mcg of estrogen and 1‐4 mg of progestin

  • Usually minimal but can be severe, even

malignant HTN

  • Risk decreases with cessation of oral

contraceptive

  • Postmenopausal HRT has minimal effect on BP in

normotensive women‐may even reduce

  • If BP not controlled‐may consider progestin only
  • r IUD

37 Grossman E, Am J Med. 2012 Jan;125(1):14‐22. Gyamlani G. South Med J. 2007 Jul;100(7):692‐9

Nonsteroidal Anti‐Inflammatory Drugs Cox‐2 Inhibitors

  • Ibuprofen, naproxen, piroxicam
  • Celecoxib
  • Implicated in increasing BP and CVD risk
  • Can antagonize effects of some BP agents
  • NSAIDS inhibit PG  vasoconstriction and

volume retention

  • Recommended

– Lifestyle changes and nonpharmacologic therapies for pain – Use lowest effective NSAID dose – Modifying antihypertensive therapy and diuretic management

38

Prostaglandins Vasodilation Excretion of sodium and water

Gyamlani G. South Med J. 2007 Jul;100(7):692‐9

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Change of BP in Hypertensives and Normotensives

39 Armstrong EP. Clin Ther. 2003 Jan;25(1):1‐18.

Atypical Antipsychotics

  • Linked to metabolic syndrome and weight gain
  • More likely with clozapine and olanzapine
  • Management

– Lower dose – Consider alternative agent and behavioral therapy

40 Whelton PK, Hypertension. 2018;71(19):e127–248.

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Stimulants

  • Nicotine, amphetamines
  • Unpredictable
  • Methylphenidate, amphetamines usually only

cause modest increases

– BP: 2‐5/1‐3 mmHg – HR: 3‐6 bpm

  • Some can experience significant increases in BP
  • r HR
  • Management

– Consider behavioral therapy

41

Grossman E, Am J Med. 2012 Jan;125(1):14‐22. Whelton PK, Hypertension. 2018;71(19):e127–248.

Cocaine, Anesthetics, Narcotics

  • Cocaine

– Abuse causes adrenergic overactivity – Acute increases in BP, but not usually chronic increases – Problematic when used while taking beta blockers

  • Ketamine
  • Naloxone

– Hypertensive responses seen in reversal of narcotics – Can acutely reverse antihypertensive effects of clonidine

42 Whelton PK, Hypertension. 2018;71(19):e127–248.

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Decongestants

  • Pseudoephedrine, phenylephrine, epinephrine,
  • xymetazoline
  • Mainly due to activation of the sympathetic nervous

system

  • Counteract pharmacological treatment
  • Sympathomimetics with beta‐blockers may increase BP

due to unopposed alpha vasoconstriction

  • Management

– Consider alternative therapies (nasal saline, intranasal corticosteroids, antihistamines)

43

Grossman E, Am J Med. 2012 Jan;125(1):14‐22. Whelton PK, Hypertension. 2018;71(19):e127–248

Caffeine

  • Potential activation of the

sympathetic nervous system

  • More pronounced in males and

African‐Americans

  • Caffeine in 2‐3 cups of coffee

can raise as much as 10 mmHg (average is 3‐5 mmHg)

  • Tolerance usually develops
  • Caffeine content in drinks vary

44 Grossman E, Am J Med. 2012 Jan;125(1):14‐22. Whelton PK, Hypertension. 2018;71(19):e127–248 Image: http://www.theprospect.net/a‐users‐guide‐to‐caffeine‐11237

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Antidepressants

  • Venlafaxine‐SNRI‐3‐13%

– Meta‐analysis showed increase

  • Dose dependent
  • Older patients
  • Men

– Elevated diastolic BP (>90 mmHg) was statistically at doses > 300 mg/day

  • Monoamine oxidase inhibitors‐selegiline
  • Thioridazine‐in overdose

45 Grossman E, Am J Med. 2012 Jan;125(1):14‐22. Whelton PK, Hypertension. 2018;71(19):e127–248

Immunosuppressive Agents

  • Cyclosporine‐BLACK BOX WARNING

– Can be mild to severe and up to 80% – 1 year after renal transplant 32.7‐81.6% – Bone marrow transplants 57% incidence of HTn vs. 4% with methotrexate – Cardiac transplant‐may be up to 100%

  • Tacrolimus‐associated much less than

cyclosporine

46 Grossman E, Am J Med. 2012 Jan;125(1):14‐22. Whelton PK, Hypertension. 2018;71(19):e127–248

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Recombinant Human Erythropoietin

  • Dose‐related
  • Reported to develop (or worsen) in 20‐30% of

patients

  • May appear as early as 2 weeks and as late as 4

months

  • Increase risk

– Pre‐existing HTN, genetic predisposition, rapid rise in hematocrit

  • Can be controlled with dialysis and

antihypertensives

47 Grossman E, Am J Med. 2012 Jan;125(1):14‐22. Whelton PK, Hypertension. 2018;71(19):e127–248

Alcohol

  • Excessive intake can raise BP and resistance to

antihypertensives

  • Increase in prevalence of 7‐11%
  • Prospective cohort study

– ~4,000 Japanese men – Greater in those who consume > 300 g/week

  • Also can see HTN with disulfiram

48 Grossman E, Am J Med. 2012 Jan;125(1):14‐22. Whelton PK, Hypertension. 2018;71(19):e127–248

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Anti‐vascular Endothelial Growth Factor (VEGF)

  • Bevacizumab

– Dose related – Severe HTN (>200/100) >3‐5‐fold higher – Up to 32% – More pronounced in elderly, preexisting HTN, renal cell carcinoma

  • Sorafenib

– Study using 24‐hour ambulatory BP monitoring, 400 mg twice a day increased systolic BP by 8.2 mm Hg, and diastolic BP by 6.5 mm Hg within 24 hours of treatment

  • Sunitinib

– Increased risk of severe HTN‐relative risk 22.7, 95% CI 4.48‐ 115.29 (p= 0.001) in comparison to controls

49 Grossman E, Am J Med. 2012 Jan;125(1):14‐22. Whelton PK, Hypertension. 2018;71(19):e127–248

Adverse effects of VEGF inhibitors

50 Rigas G. Current Vascular Pharmacology (2018) 16: 23.

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Antiretroviral therapy‐Protease Inhibitors

  • May increase more than 10 mmHg (systolic or

diastolic)

  • Elevations more likely in elderly, higher baseline

systolic BP, higher cholesterol, low CD4 count

  • Usually seen more with the therapy that causes

metabolic changes

– Highest risk with lopinavir/ritonavir

  • Drug interaction with calcium channel blockers

51 Grossman E, Am J Med. 2012 Jan;125(1):14‐22.

Herbal Products

  • Yohimbine

– Increases norepinephrine and sympathetic activation – Interacts with clonidine

  • Ginseng

– Information to suggest increase or decrease

  • Ma huang/ephedra

– Many case reports involving young adults

  • St John’s Wort

52 Grossman E, Am J Med. 2012 Jan;125(1):14‐22.

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53 http://www.heart.org/HEARTORG/

Patient Case

  • 76 year old female presents to the pharmacy with

a new prescription for clonidine. When talking with the patient, she reports “my doctor put me

  • n another new medication to help control my

high blood pressure”

  • Current medications: hydrochlorothiazide 25 mg

daily, losartan 100 mg daily, metoprolol 50 mg twice daily, amlodipine 10 mg daily

  • She reports that her blood pressures at home are

in the “150s on the top”

54

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Patient Case (continued)

  • When you question her about any medications

that she takes OTC or supplements‐she reports that she takes ibuprofen 3 tabs daily for her arthritis and ginger to help with her nausea.

  • You also verify how (and if) she is taking all of

her medications.

  • What medications might be worsening her

blood pressure?

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Strategies to Help with Adherence

56

  • Simplify the regimen

S

  • Impart knowledge

I

  • Modify patients’ beliefs and behavior

M

  • Provide communications and trust

P

  • Leave the bias

L

  • Evaluate adherence

E

Millionhearts.hhs.gov

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57

Conclusion

  • Hypertension affects many Americans
  • Controlling hypertension can help prevent

complications

  • In most cases, the cause of hypertension is

unknown

  • Identifying agents that can increase blood

pressure can help patients to improve control

  • All patients should follow lifestyle modifications

58

Contact Information

  • Melanie.Claborn@swosu.edu
  • Melanie.c@okcic.com
  • 405‐948‐4900

extension 494

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References

  • Benjamin EJ, Muntner P, Alonso A, et al. on behalf of the American Heart Association Council on

Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics—2019 update: a report from the American Heart Association [published online ahead of print January 31, 2019]. Circulation. doi: 10.1161/CIR.0000000000000659. Accessed May 2, 2019.

  • Heart Disease and Stroke Statistics 2019 Infographic https://healthmetrics.heart.org/heart‐disease‐and‐

stroke‐statistics‐2019‐infographic/ Accessed May 2, 2019.

  • Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/

ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults. A Report of the American college of cardiology/American heart association task force

  • n clinical practice guidelines. Hypertension. 2018;71(19):e127–248.
  • Chobanian AV, et al. Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation,

and Treatment of High Blood Pressure (2003). National Heart, Lung, and Blood Institute; National High Blood pressure Education Program Coordinating Committee. Hypertension. 2003; 42: 1206‐1252

  • Ogden LG, et al. Long‐term absolute benefit of lowering blood pressure in hypertensive patient according

to the JNC VI risk stratification. Hypertension 2000; 35: 539‐543.

  • James PA, Oparil S, Carter BL, et al. 2014 evidence‐based guideline for the management of high blood

pressure in adults. JAMA 2014;311:507‐20.

  • Grossman E, Messerli FH. Drug‐induced hypertension: an unappreciated cause of secondary hypertension.

Am J Med. 2012 Jan;125(1):14‐22. doi: 10.1016/j.amjmed.2011.05.024.

  • Rigas G. Kalaitzidis, Elisaf MS. “Uncontrolled Hypertension and Oncology: Clinical Tips”, Current Vascular

Pharmacology (2018) 16: 23.

  • Gyamlani G, Geraci SA. Secondary Hypertension due to Drugs and Toxins. South Med J. 2007

Jul;100(7):692‐9.

59

References

  • Weber MA, Schiffrin EL, White WB, et al. Clinical practice guidelines for the management of hypertension

in the community. J Clin Hypertens 2014;16:14‐26.

  • Hackam DG, Quinn RR, Ravani P, et al. The 2013 Canadian Hypertension Education Program

recommendations for blood pressure measurement, diagnosis, assessment of risk, prevention, and treatment of hypertension. Can J Cardiol 2013;29:528‐42.

  • Mancia G, Fagard R, Narkiewicz K, et al. 2013 ESH/ESC guidelines for the management of arterial
  • hypertension. J Hypertens 2013;31:1281‐357.
  • American Diabetes Association (ADA). Standards of medical care in diabetes – 2019. Diabetes Care Jan

2019, 42 (Supplement 1) DOI: 10.2337/dc19‐Sint01. Accessed Jan 21, 2019.

  • Cardiovascular Disease and Risk Management: Standards of Medical Care in Diabetes—2019. American

Diabetes Association. Diabetes Care Jan 2019, 42 (Supplement 1) S103 S123; DOI: 10.2337/dc19‐S010

  • Smith SC, Benjamin EJ, Bonow RO, et al. AHA/ACCF secondary prevention and risk reduction therapy for

patients with coronary and other atherosclerotic vascular disease: 2011 update. Circulation 2011;124:2458‐73.

  • Kidney Disease: Improving Global Outcomes (KDIGO) Blood Pressure Work Group. KDIGO clinical practice

guideline for the management of blood pressure in chronic kidney disease. Kidney Int Suppl 2012;2:337‐ 414.

  • Aronow WS. Drug‐induced causes of secondary hypertension. Ann Transl Med. 2017;5(17):349.

doi:10.21037/atm.2017.06.16

  • Onusko E. Diagnosing secondary hypertension. Am Fam Physician. 2003 Jan 1;67(1):67‐74.
  • Armstrong EP, Malone DC The impact of nonsteroidal anti‐inflammatory drugs on blood pressure, with an

emphasis on newer agents. Clin Ther. 2003 Jan;25(1):1‐18.

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Self‐Check

61

Post‐Assessment Question:

What is the leading cause of death in the United States?

  • a. Heart disease
  • b. Cancer
  • c. Accidents
  • d. Influenza

62

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Post‐Assessment Question:

A patient has blood pressure readings in the clinic that are consistently 136/82. How would you classify his blood pressure?

  • a. Normal
  • b. Elevated
  • c. Stage 1 HTN
  • d. Stage 2 HTN

63

Post‐Assessment Question: Which of these medications can be associated with increasing blood pressure?

  • a. Cyclosporine
  • b. Erythropoietin
  • c. Indomethacin
  • d. All of the above

64

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65

http://www.taxguru.net

Stress‐Does it increase BP? Caution: Contents Under Pressure Identifying Drug‐Induced Hypertension

Melanie Claborn, Pharm.D., BCACP Assistant Professor of Pharmacy Practice Southwestern Oklahoma State University College of Pharmacy Clinical Pharmacy Specialist‐Oklahoma City Indian Clinic Oklahoma City, OK

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