A 69-year-old male underwent elective percutaneous coronary intervention requiring placement of a drug-eluting stent to the first obtuse marginal artery. Four hours following the administration of a ticagrelor loading dose, he developed dyspnea and sinus pauses. Aminophylline was administered and resulted in immediate and sustained symptom resolution. Ticagrelor has been associated with dyspnea and bradyarrhythmias, both attributed to increased adenosine exposure. Ticagrelor inhibits reuptake of intracellular adenosine. Adenosine antagonists aminophylline and theophylline have been utilized to reverse the effects of adenosine and may relieve adenosine-mediated adverse effects induced by ticagrelor therapy. Aminophylline may be considered for reversal of dyspnea and bradyarrhythmia associated with ticagrelor therapy through alterations in adenosine exposure.
Despite the positive data on clinical outcomes, cost savings, and provider experience, no study has surveyed providers to evaluate what pharmacy services they find to be worthwhile.
To determine what clinical, cost/access, and educational pharmacy services providers in a patient-centered medical home (PCMH) consider worthwhile and the perceived barriers to successful pharmacist incorporation.
A cross-sectional online survey was distributed to primary care physicians, nurse practitioners, and physician assistants in a PCMH physician group.
The survey response rate was 78%. Top-tier clinical services were identified as medication counseling, reconciliation, adherence assessment, polypharmacy assessment, and drug information. Formulary review was the only top-tier cost- or access-related service. Top-tier educational services included new black-boxed warnings, drug market withdrawals, and new drug reviews. Ninety-one percent of providers were comfortable referring to a pharmacist for diabetes medication selection and dose titration, but no other disease state eclipsed 75%. More than twice as many providers found the pharmacy service to be very or extremely valuable when the pharmacist is physically located in the office versus virtual interactions (70% vs 34%).
Top-tier clinical, cost/access, and educational services considered worthwhile by providers in a PCMH have been identified. In addition to these services, when developing or evaluating a pharmacy service, special attention should be paid to provider preference for physical location in the office and perceived barriers to the pharmacist availability, concern over complex disease management competency and patient confusion as to the role of the pharmacist.
Sodium–glucose cotransporter 2 (SGLT2) inhibitors have been associated with serious urinary tract infections (UTIs) including pyelonephritis and urosepsis. The Food and Drug Administration (FDA) issued a label change to include this warning in December 2015 due to a small number of cases (n = 19) reported to the FDA Adverse Event Reporting System. Details of these cases are limited and none involved empagliflozin. To date, there has been no published literature comprehensively describing serious UTIs attributed to empagliflozin. We describe a case of septic shock due to Serratia marcescens pyelonephritis and bacteremia that required intensive care unit admission in a well-controlled, type 2 diabetic patient who had begun taking empagliflozin 2 months prior. The patient was treated successfully with intravenous antibiotics followed by oral ciprofloxacin. After discontinuation of empagliflozin and completion of antibiotic therapy, no subsequent UTIs were documented in the following 4 months.
To describe 2 cases of angiotensin-converting enzyme inhibitor (ACEI)-induced angioedema treated with C1 esterase inhibitor (human) [Berinert].
Case 1 is a 60-year-old Caucasian male with angioedema from lisinopril. He was initially treated with a conventional regimen of an antihistamine, methylprednisolone, epinephrine, and fresh frozen plasma. When symptoms did not resolve, intravenous C1 peptide esterase inhibitor (C1INH) was administered, with clinical improvement. Four hours later, symptoms returned and the patient underwent emergency tracheostomy. Case 2 is a 64-year-old Caucasian male who presented with angioedema due to enalapril. In the emergency department, he received conventional treatment. Endotracheal tube placement was unsuccessful. While the patient was undergoing intubation in the operating room, intravenous C1INH was administered resulting in quick improvement of symptoms.
Angioedema from ACEI occurs at an incidence of 0.7%. Conventional treatment may be of limited benefit due to the mechanism of the reaction. C1INHs, which are indicated for hereditary angioedema, have been utilized in treating ACEI-induced angioedema. According to the Naranjo algorithm scale, the patient in case 1 experienced angioedema that is probably related to lisinopril. C1INH was administered intravenously when symptoms progressed, despite conventional treatment. In case 2, the patient experienced angioedema, which is possibly related to enalapril, and was treated with C1INH.
C1INH (human) was a successful addition to the traditional management of 2 patients with angioedema due to ACEI.
Tissue plasminogen activator (tPA) is the only pharmacotherapy shown to improve outcomes in acute ischemic stroke. The American Heart Association (AHA) recommends a door-to-needle (DTN) time of
The purpose of this study was to analyze the possible barriers that may delay tPA administration within the emergency department (ED) of an academic medical center.
A retrospective chart review was conducted from February 2011 to October 2013. Patients were included if they were admitted through the ED with a diagnosis of acute ischemic stroke and received tPA.
Of the 130 patients who met inclusion criteria, 43.1% received tPA in ≤60 minutes. Several factors were identified to be significantly different in those with a DTN time of >60 minutes—time to ED physician consultation, neurologist arrival, blood sample acquisition, and result time (P < .05 for all comparisons). Correlation analysis demonstrated several independent variables associated with DTN time of ≤60 minutes—time from admission to ED physician consultation, receipt of computed tomography (CT) scan, blood sample acquisition, laboratory results, and neurology service arrival (P < .05 for all comparisons).
The findings from this study highlight the importance of prompt physician evaluation, direct transfer to the CT scanner, and a quick turnaround time on laboratory values. The development of protocols to ensure the rapid receipt of tPA therapy should focus on limiting any potential delay these steps may cause.
A 91-year-old male was admitted to the hospital for worsening muscle weakness, muscle pain, and unexplained soreness for the past 10 days. Four months prior to his admission, the patient had experienced a myocardial infarction and was initiated on atorvastatin 80 mg daily. Although the provider had instructed the patient to decrease the atorvastatin dose to 40 mg daily 3 months prior to admission, the patient did not adhere to the lower dose regimen until 10 days prior to hospitalization. Upon admission, the patient presented with muscle weakness and pain, a serum creatinine phosphokinase of 18 723 U/L, and a serum creatinine of 1.6 mg/dL. The atorvastatin dose was held and the patient was treated with intravenous fluids. The 2013 American College of Cardiology and American Heart Association Blood Cholesterol Practice Guidelines recommend the use of moderate-intensity statins in patients older than 75 years to prevent myopathy. However, in clinical practice, aggressive statin therapy is often prescribed for significant coronary disease. Prescribing high-intensity statins for patients with advanced age, such as this case, may increase the risk of rhabdomyolysis and other complications. This case report suggests that providers should avoid or be cautious with initiating high-intensity atorvastatin in elderly patients over 75 years to minimize the risk of rhabdomyolysis.
Statins are the primary class of medications used to lower cholesterol and reduce risks for coronary heart disease. However, statin muscular adverse effects are one of the main reasons for statin nonadherence and a barrier to cardiovascular risk reduction.
The primary objective of our study was to examine the effect of replenishing vitamin D on statin-induced myopathy in veteran patients who failed to maintain statin therapy in a pharmacist-run ambulatory care setting. Secondary objectives were to examine changes in patients’ vitamin D levels, fasting lipid profiles, and achievement of lipid goals after reinitiation of statin therapy.
This was a retrospective cohort study of veteran patients conducted at a pharmacist-managed cholesterol-optimization clinic. Patients with low-serum vitamin D, history of statin-induced myopathy, and who received vitamin D replenishment prior to rechallenging statin therapy between December 1, 2008, and April 1, 2015, were identified. The primary outcome was the percentage of patients who maintained their statin therapy at 12 months after statin reinitiation.
Twenty-seven patients met the study criteria. All patients were able to maintain their statin therapy without myalgia after vitamin D supplementation. Eleven patients (40.7%) tolerated their previously failed statins. The most frequently restarted statins were atorvastatin, pravastatin, and rosuvastatin. A 22% to 30% increase in the number of patients who achieved cholesterol goals based on the national lipid guidelines was observed at 12-month follow-up.
Replenishing low vitamin D in patients with statin-induced myopathy appears to be an effective strategy in improving medication adherence and subsequently preventing cardiovascular and mortality events.
Systemic absorption of oral vancomycin for the treatment of Clostridium difficile is thought to be trivial in patients without risk factors for increased systemic absorption and is often overlooked in clinical practice. A 51-year-old male elicits a suspected immunoglobulin E-mediated hypersensitivity following administration of low-dose oral vancomycin for the treatment of severe C difficile. The patient had normal renal function and was administered low doses of the medication, however, had a medical history significant for diverticulitis. Applying the Naranjo adverse drug reaction probability scale, a score of 5 was obtained, indicating a probable association between the administration of oral vancomycin and the hypersensitivity reaction. This case demonstrates that hypersensitivity reactions following low-dose oral vancomycin administration in patients with severe C difficile are possible, despite having normal renal function. Other risk factors for systemic absorption of oral vancomycin need to be evaluated in the literature, including severity of disease and underlying gastrointestinal processes.
The primary approach to controlling diabetes involves diet and lifestyle modification combined with pharmacologic interventions. Patients who are interested in exploring dietary supplements in the management of diabetes may have questions about which supplement to choose and whether any issues will arise with their current medication regimen. After reading this review, the pharmacist should be able to identify supplements that may provide benefit to improve diabetes management, understand what potential harm to the patient may occur, and be able to assist the patient in choosing high-quality supplements. This review will focus on the safety and efficacy data surrounding nicotinamide, ginseng, fenugreek, vitamin D, chromium, and cinnamon. These supplements are commonly listed in general circulation periodicals with claims to improve blood sugar management. Efficacy data showed a modest decrease in fasting plasma glucose of –0.96 mmol/dL (–17.29 mg/dL) for fenugreek and –24.59 mg/dL for cinnamon. It remains to be seen whether supplementation with these products can affect outcomes such as morbidity and mortality. Despite many studies being available, the majority lack uniformity across multiple dimensions, including varying participant characteristics, inconsistent formulations of supplement and dose, and differing study durations. This, coupled with variation in quality and purity of commercially available products, prevents universal recommendation for use in diabetes management.
Maintaining potassium balance in the body is essential for cellular function. Even a slight increase in normal serum potassium levels (3.5-5.0 mEq/L) can interfere with metabolism, electrical action potentials, and cellular processes. Hyperkalemia is commonly seen in patients with chronic kidney disease (CKD) and in patients on renin–angiotensin–aldosterone system (RAAS) inhibitors. Sodium polystyrene sulfonate (SPS), diuretics, and hemodialysis are currently available methods for removing potassium from the body; however, these options have their limitations. Patiromer (Veltassa) and sodium zirconium cyclosilicate are 2 new therapeutic options that can potentially lead a new frontier in the management of hyperkalemia. This article will review these novel treatments.
Medication nonadherence contributes to approximately US$290 billion per year in avoidable health-care spending. Statins are of particular interest because of their importance to patient outcomes, costs of treatment failure, and categorization as a Medicare star measure linked to financial reimbursement.
To evaluate statin adherence as defined by the proportion of days covered (PDC) among patients who use an embedded dispensing pharmacy in a patient-centered medical home (PCMH).
This study is a retrospective chart review of Lifetime Health Medical Group’s electronic health record and third-party prescription claims data of statin therapy. Statin adherence is reported using PDC, with 0.8 or greater considered adherent for statin therapy. Statistics used include 2-sample unpaired t test to compare PDC between gender and age, and analysis of variance was used to determine differences in PDC among different insurance types.
One hundred ninety-three patients were included, and 917 statin prescriptions were filled. PDC for statin medications in the population was 0.92 ± 0.20. Eighty-six percent of patients were considered adherent, with a PDC ≥80%. The average insurance and patient costs for brand prescriptions (n = 106) were US$233 ± US$143 and US$31 ± US$27, respectively, and costs for generic prescriptions (n = 811) were US$8 ± US$13 and US$7 ± US$6, respectively.
Statin adherence rates for patients utilizing a dispensing pharmacy embedded in a large PCMH exceed the national average of 40% to 50% adherence.
The Beers Criteria identifies potentially inappropriate medications for patients who are 65 years of age and older. Initially published in 1991, the criteria have been updated multiple times, most recently in 2015. The Beers Criteria is a tool designed to alert health-care providers to the potential harms of specific medications so they may better tailor therapeutic regimens for their elderly patients. The expert panel of the 2015 update made changes to a number of previous recommendations and provided 2 new tables on select drug interactions and select medications requiring renal dose adjustments. The purpose of this review is to provide additional details and rationale behind selected noteworthy changes within the 2015 criteria. Specific information is provided on the changes in recommendations for the use of nitrofurantoin, antiarrhythmics, nonbenzodiazepine receptor agonist hypnotics, antipsychotics, and proton pump inhibitors in the elderly. Additional comparisons are made between the 2012 recommendations and newer recommendations made in the 2015 update, along with rationale for the change. This review will allow practitioners to apply the 2015 Beers Criteria and integrate their clinical judgment when evaluating and selecting drug therapy for elderly patients.
To review the use of continuous infusion (CI) nonsteroidal anti-inflammatory drugs (NSAIDs) as an alternative modality for pain control in surgical patient populations.
A PubMed and MEDLINE search was conducted from 1964 through February 2016 using the following search terms alone or in combinations: continuous, infusion, nonsteroidal anti-inflammatory drug, diclofenac, ibuprofen, indomethacin, ketoprofen, ketorolac, and surgery. All English-language, prospective and retrospective, adult and pediatric studies evaluating intravenous or intramuscular CI NSAIDs for surgical pain were evaluated for inclusion in this review.
Twenty four prospective and retrospective publications evaluating CI NSAIDs were identified: 12 in abdominal surgery, 7 in orthopedic surgery, and 5 in pediatric surgery. Specific CI NSAIDs utilized included diclofenac, indomethacin, ketoprofen, and ketorolac. Most studies compared the CI NSAID to placebo or an alternative analgesic and evaluated pain control, supplemental opioid use, and related adverse effects. In these surgical populations, CI NSAIDs decreased opioid consumption, alongside provision of adequate pain control. While long-term adverse effects were rarely collected, a decrease in nausea and sedation was often seen with the CI NSAID groups.
In the abdominal, orthopedic, and pediatric surgical populations, CI NSAIDs represent a feasible alternative modality for perioperative pain control.
There are insufficient data in the United States regarding patient awareness and expectations of hospital pharmacist availability and services.
The objective of this research is to assess patient awareness and expectations of hospital pharmacist services and to determine whether a marketing campaign for pharmacist services increases patient awareness and expectations.
Eligible inpatients were surveyed before and after implementation of a hospital-wide pharmacist services marketing campaign (12 items; Likert scale of 1 [strongly disagree] to 4 [strongly agree]; maximum total score of 48) regarding awareness of pharmacist services. The primary outcome was the change in median total survey scores from baseline. Other outcomes included the frequency of patient requests for pharmacists.
Similar numbers of patients completed the survey before and after the campaign (intervention, n = 140, vs control, n = 147). Awareness of pharmacist availability and services was increased (41 [interquartile ranges, IQRs: 36-46] vs 37 [IQR 31-43]; P < .001). Patients were 7 times more likely to request a pharmacist following the marketing campaign implementation.
Awareness among inpatients of pharmacist services is low. Marketing pharmacist availability and services to patients in the hospital improves awareness and expectations for pharmacist-provided care and increases the frequency of patient-initiated interaction between pharmacists and patients. This could improve patient outcomes as pharmacists become more integrally involved in direct patient care.
To show that clinical pharmacy specialists (CPSs) can be utilized in remote facilities to provide appropriate diabetes outcomes along with potential cost savings.
A retrospective cohort chart review conducted at the Veterans Affairs North Texas Healthcare System (VANTHCS) evaluated outcomes in patients with type 2 diabetes mellitus referred to CPSs at Fort Worth Outpatient Clinic (FWOPC) or the endocrinologist-managed specialty clinic at the Dallas VA Medical Center (DVAMC). The primary outcome was percentage of patients reaching hemoglobin A1c (HbA1c) goal of <8%. Secondary outcomes were percentage of patients reaching HbA1c <7%, time to reach HbA1c goals of <8% and <7%, and cost savings.
There was no statistically significant difference in the number of patients reaching HbA1c goal <8% in the FWOPC (65.3%) compared to the DVAMC (55.8%). Secondary end points comparing FWOPC and DVAMC found no difference in patients reaching HbA1c <7% (20.8% vs 19.2%) and time to reach HbA1c goal of <8% (4.5 vs 6 months) and <7% (8.5 vs 7.5 months). Cost-saving analysis demonstrated a composite of US$350 292 could be saved by the VANTHCS facility if patients continued to be referred to CPS.
CPSs can be utilized in diabetes management to provide similar health outcomes as the endocrinologist-managed clinic and to potentially allow for facility cost savings.
We describe a 70-year-old Haitian man who had been taking warfarin for 5 years for atrial fibrillation and pulmonary hypertension. This patient had his international normalized ratio (INR) checked in the pharmacist-run anticoagulation clinic and was followed monthly. Prior to the interaction, his INR was therapeutic for 5 months while taking warfarin 10.5 mg/d. The patient presented with an INR > 8.0. Patient held 4 days of warfarin and restarted on warfarin 8.5 mg/d. Two weeks later, his INR was 2.5. After continuing dose, patient presented 2 weeks later and INR was 4.8. Upon further questioning, the patient stated he recently began ingesting mauby. Mauby is a bitter dark liquid extracted from the bark of the mauby tree that is commonly used in the Caribbean population as a folk remedy with many health benefits. This case report illustrates that mauby may have a probable drug–herb interaction (Naranjo Algorithm Score of 6) when given with warfarin. There is a lack of published literature and unclear information on the Internet describing the interaction of mauby and warfarin. Health professionals should be cautious regarding interactions between warfarin and mauby until the interaction is fully elucidated.
Smoke inhalation injury (SIJ) is associated with an increase in morbidity and mortality in patients with burns. SIJ causes airway damage, inflammation, and bronchial obstruction, resulting in decreased oxygenation and perfusion status in these patients. Retrospective studies have compared the use of nebulized heparin (NH) plus nebulized N-acetylcysteine (NAC) and albuterol in patients with SIJ to those who received standard ventilator support with bronchodilator therapy. These studies are associated with a decrease in mortality when NH and nebulized NAC are administered to patients with SIJ. Approximately 20% of patients who develop SIJ will also develop acute respiratory distress syndrome (ARDS). Epoprostenol, a selective pulmonary vasodilator, has been utilized in the treatment of ARDS with mixed results for improving gas exchange. To our knowledge, this is the first case report of the concomitant administration of NH, nebulized NAC, and nebulized epoprostenol following SIJ in a burn patient with ARDS.
To review primary literature of gastric acid suppressive agents and vitamin B12 deficiency.
From the published articles, proton pump inhibitors (PPIs) are associated with a higher risk of inducing vitamin B12 deficiency than histamine-2 receptor antagonists (H2RAs). Literature suggests that there is an increased risk of developing vitamin B12 deficiency in patients who are exposed to extended durations of therapy with PPIs. There are, however, some conflicting data in elderly patients suggesting that the PPI use for more than 3 years does not increase the risk of vitamin B12 deficiency. No evidence was found to support the extended use of H2RA monotherapy causing vitamin B12 deficiency. The inconsistency of results reported could be due to the differing patient populations studied, such as Zollinger-Ellison syndrome (ZES) and elderly patients. Overall, the lack of consistent evidence shows the need for more research in this area.
To investigate the clinical significance of vitamin B12 deficiency caused by acid suppression with PPIs and H2RAs, longer prospective studies are needed. These studies should focus on patient-centered outcomes to accurately determine the extended usage of PPI and H2RA and the true effects on vitamin B12 deficiency.
Fungal diseases of the nail bed (onychomycosis) and epidermis are recurrent illnesses in the elderly and immunocompromised patients, which have few efficacious treatment options. Current treatment options for onychomycosis are limited to topical agents, laser treatment, and oral antifungals. Previous generations of topical agents were not efficacious, owing to poor penetration of the nail bed. Oral antifungal drugs, such as itraconazole, terbinafine, and fluconazole, not only give better response rates but also inhibit a host of CYP450 enzymes. Oral antifungals can exacerbate drug–drug interactions for patients taking other medications concurrently. Newer topical agents might recognize improved efficacy and provide therapeutic alternatives when the use of oral antifungal agents is contraindicated. Recently, the Food and Drug Administration (FDA) approved efinaconazole and tavaborole for the treatment of onychomycosis. Additionally, the FDA approved luliconazole for the treatment of tinea pedis, tinea cruris, and tinea corporis. This review examines the mechanism of action, spectrum of activity, pharmacokinetics, and clinical trials data and considers the place in therapy for these 3 new antimycotic agents.
Benzodiazepines are prescribed inappropriately in up to 40% of outpatients. The purpose of this study is to describe a collaborative team-based care model in which clinical pharmacists work with primary care providers (PCPs) to improve the safe use of benzodiazepines for anxiety and sleep disorders and to assess the preliminary results of the impact of the clinical service on patient outcomes.
Adult patients were eligible if they received care from the academic primary care clinic, were prescribed a benzodiazepine chronically, and were not pregnant or managed by psychiatry. Outcomes included baseline PCP confidence and knowledge of appropriate benzodiazepine use, patient symptom severity, and medication changes.
Twenty-five of 57 PCPs responded to the survey. PCPs reported greater confidence in diagnosing and treating generalized anxiety and panic disorders than sleep disorder and had variable knowledge of appropriate benzodiazepine prescribing. Twenty-nine patients had at least 1 visit. Over 44 total patient visits, 59% resulted in the addition or optimization of a nonbenzodiazepine medication and 46% resulted in the discontinuation or optimization of a benzodiazepine. Generalized anxiety symptom severity scores significantly improved (–2.0; 95% confidence interval (CI): –3.57 to –0.43).
Collaborative team-based models that include clinical pharmacists in primary care can assist in optimizing high-risk benzodiazepine use. Although these findings suggest improvements in safe medication use and symptoms, additional studies are needed to confirm these preliminary results.
To evaluate the efficacy of a smoking cessation program led by a pharmacist and a nurse practitioner.
During a 6-month period, patients attended 7 one-on-one face-to-face smoking cessation counseling sessions with a pharmacist and 1 to 2 one-on-one face-to-face smoking cessation counseling sessions with a nurse practitioner. The primary outcome was smoking cessation point prevalence rates at months 1, 3, and 5 post-quit date. Secondary outcomes included medication adherence rates at months 1, 3, and 5 post-quit date, nicotine dependence at baseline versus program end, and patient satisfaction.
Nine (47%) of 19 total participants completed the program. Seven of the 9 patients who completed the program were smoke-free upon study completion. Point prevalence rates at months 1, 3, and 5 post-quit date were 66%, 77%, and 77%, respectively, based on patients who completed the program. Medication adherence rates were 88.6%, 54.6%, and 75% at months 1, 3, and 5 post-quit date, respectively. Based on the Fagerstrom test, nicotine dependence decreased from baseline to the end of the study, 4.89 to 0.33 (P < .001). Overall, participants rated the program highly.
A joint pharmacist and nurse practitioner smoking cessation program can assist patients in becoming smoke-free.
Etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin (EPOCH)-containing regimens are frequently utilized in non-Hodgkin’s lymphoma, however, the incidence of febrile neutropenia (FN) in patients receiving inpatient versus outpatient EPOCH has not been described. Additionally, no comparisons have been made regarding financial implications of EPOCH administration in either setting. This study’s primary objective was to compare hospital admissions for FN in patients receiving inpatient or outpatient EPOCH.
A single-center, institutional review board-approved review was conducted for adults receiving EPOCH beginning January 2010. Clinical and financial data were collected through chart review and the institution’s financial department. Descriptive statistics were utilized for analysis.
A total of 25 patients received 86 cycles of an EPOCH-containing regimen (61 [70.9%] inpatient). Five (8.2%) inpatient cycles resulted in an admission for FN compared to 4 (16%) outpatient cycles. Prophylactic antifungal and antiviral agents were prescribed more often after inpatient cycles (>80%) compared to outpatient cycles (<50%). Overall, 27 (31.4%) of 86 cycles did not receive granulocyte colony-stimulating factor support. Outpatient EPOCH administration was associated with a cost savings of approximately US$141 116 for both chemotherapy costs and hospital day avoidance.
EPOCH-containing regimens can be safely administered in the outpatient setting, which may result in cost savings for healthcare institutions.
Opioid misuse imposes a disproportionately heavy burden on individuals living in rural areas. Community pharmacy has the potential to expand and coordinate with health professionals to identify and intervene with those who misuse opioids.
Rural and urban community pharmacy patients were recruited in this pilot project to describe and compare patterns of opioid misuse.
We administered a health screening survey in 4 community pharmacies among patients filling opioid medications. Univariate statistics were used to assess differences in health characteristics and opioid medication misuse behaviors between rural and urban respondents. Multivariable statistics were used to identify risk factors associated with rural and urban opioid misuse.
A total of 333 participants completed the survey. Participants in rural settings had poorer overall health, higher pain levels, lower education, and a higher rate of unemployment compared to patients in urban pharmacies. Rural respondents with illicit drug use (adjustable odds ratio [aOR]: 14.34, 95% confidence interval [CI] = 2.16-95.38), posttraumatic stress disorder (aOR: 5.44, 95% CI = 1.52-19.50), and ≤high school education (aOR: 6.68, 95% CI = 1.06-42.21) had increased risk for opioid misuse.
Community pharmacy represents a promising resource for potential identification of opioid misuse, particularly in rural communities. Continued research must extend these findings and work to establish collaborative services in rural settings.
Hydroxychloroquine (HQ) is commonly prescribed for autoimmune diseases such as systemic lupus erythematosus. We report a case of a 75-year-old female presenting with de novo decompensated heart failure and restrictive cardiomyopathy (left ventricular ejection fraction: 40%-45%) after treatment with HQ for more than 11 years. Hydroxychloroquine was discontinued, and follow-up echocardiogram 57 days after discontinuation showed normalization of her left ventricular ejection fraction. A score of 7 on the Naranjo Adverse Drug Reaction Probability Scale indicates that HQ is a probable cause of this patient’s cardiomyopathy. An adverse drug effect due to HQ should be considered in treated patients who present with restrictive cardiomyopathy. Discontinuation may allow for partial or complete reversal of the cardiomyopathy.
Device manufacturers have improved technology since studies were last published, thus warranting an updated analysis.
Two point-of-care (POC) cholesterol testing devices were directly compared to a venous sample to determine device accuracy.
Institutional review board (IRB)–approved study collected finger-stick blood samples analyzed by Cholestech LDX (Cholestech Corporation, Hayward, California) and CardioChek Plus (Polymer Technology Systems Inc, Indianapolis, Indiana) devices and compared to venous blood for 30 study participants. Statistical analyses were completed using StatisPro. Intraclass correlation coefficients were generated, and the average difference expected to be within the industry standards of total cholesterol (TC; ±10%), high-density lipoprotein (HDL) cholesterol (±12%), and triglycerides (TG; ±15%).
The POC devices produced clinically equivalent values when compared to the same patients’ samples analyzed in a reference laboratory. The average difference calculated from the actual individual paired percentage bias with the Integra analyzer: venous—TC –3.8%, HDL –6.9%, TG –1.8%; CardioChek—TC –7.8%, HDL –6.2%, TG 5.1%; and Cholestech—TC 0.5%, HDL –4.5%, TG –3.3%. The average of the actual paired percentage bias with the Roche Cobas analyzer: CardioChek—TC –4.2%, HDL 0.8%, TG 7.0% and Cholestech—TC 4.6%, HDL 2.6%, TG –1.6%.
Both screening devices operated within industry accuracy standards.
This article aims to explore the statistics observed in the Pacific Northwest regarding substance abuse, as Oregon and Washington have been shown to be most affected given the increased treatment admissions for opioid utilization and mortality related to medication overdose.
Using PubMed and National Conference of State Legislatures database, articles detailing prescription drug abuse statistics, programs, and laws were collected and analyzed in order to identify possible solutions.
Many studies report that pain medication prescriptions have seen a rise in recent years, however, there still exists an inadequacy in pain management. This increase in prescriptions may also contribute to the rising number in substance misuse and subsequently overdose deaths. Pharmacists can have a global effect on abuse prevention if certain monitoring strategies are implemented and enforced.
Health-care providers and pharmacists should contribute to abuse prevention by helping to detect fraudulent prescriptions, staying up to date with current guidelines, and being aware of new safety programs such as prescription drug monitoring programs (PDMPs).
The American College of Cardiology Foundation/American Heart Association (ACCF/AHA) guidelines consider angiotensin-converting enzyme (ACE) inhibitors as one of the mainstay therapies in the management of heart failure. The widespread use of ACE inhibitors has been associated with several notable adverse effects such as hyperkalemia and an increased serum creatinine. There are no previous reports of alopecia associated with lisinopril use; however, a few previous cases of alopecia associated with other ACE inhibitors exist. This report discusses a case of lisinopril-induced alopecia of a 53-year-old male presenting to our outpatient heart failure clinic with a chief complaint of a new onset of alopecia. Upon evaluation, it was suspected that the patient’s alopecia was likely medication induced by lisinopril; therefore, lisinopril was discontinued and switched to an angiotensin receptor blocker (ARB), losartan potassium. Alopecia resolved in 4 weeks after the therapeutic intervention. Our report suggests that the patient likely experienced a medication-induced alopecia, which was successfully resolved through proper identification and removal of the causative agent. Causality assessment between lisinopril and alopecia was determined using the Naranjo Adverse Drug Reaction Probability Scale—a total score of 6 was achieved and thus identified the adverse drug reaction as probable. Clinicians should be aware of the possibility that lisinopril may be an offending agent in a patient with unexplained alopecia.
Pharmacy students need to be equipped with skills to research and evaluate literature to effectively apply evidence-based medicine (EBM) in practice. To prepare them, a 3-stage approach to writing a drug information consult (3sDIC) was incorporated into a pharmacy course. The primary objective was to assess students’ abilities to retrieve and analyze literature pursuant to a drug information consult. Secondary objectives were to examine feasibility of faculty participation and continuation of the assignment.
Ninety students were given a clinical scenario about a patient. The assignment consisted of 3 stages incorporating use of the Population, Intervention, Comparison intervention, Outcome (PICO) method and modified systematic approach (MSA) for stage 1, evaluation of primary literature to write a draft for stage 2, and stage 3, the final consult. All 3 stages were reviewed and graded by faculty.
All students completed the 3sDIC, with no grade failures. The rubric employed by faculty was effective, providing students the opportunity to improve the consult. The 3sDIC was found to be feasible with adequate faculty support.
The 3sDIC, although not a substitute for a complete drug information course, demonstrated a streamlined approach for Pharmacy year 2 (P2) students to acquire and develop drug information skills.
Nonsteroidal anti-inflammatory drugs (NSAIDs) are a group of heterogeneous drugs largely known for their anti-inflammatory, antipyretic, and analgesic effects, which are met by means of the inhibition of the cyclooxygenase (COX) enzymes. Even when their use in patients with diabetes mellitus is limited due to relevant adverse events, some pharmacological and metabolic effects of NSAIDs have been further studied to be potentially beneficial in the prevention and/or treatment of diabetic subjects. Effects on endogenous glucose production, peripheral insulin resistance, pancreatic islet, and systemic inflammation and the insulin clearance have been reported. In this article, we overview the scientific literature of the last 5 years regarding the potential effects of NSAID treatment on diabetes prevention/treatment. The selected papers showed information in both humans and animal models. Furthermore, we included papers that suggest new areas for further investigation, and we discussed our own suggestions on this matter.
Despite availability of standardized drug therapies with proven beneficial outcomes, heart failure is associated with poor quality of life, increased hospital readmission, and high mortality rate. In the recent years, comprehensive understanding of the pathophysiological mechanisms of heart failure has led to the development and approval of 2 new pharmacological agents, sacubitril–valsartan and ivabradine. These agents are currently approved for use in heart failure with reduced ejection fraction (HFrEF) and present as novel approaches to further improve prognosis and outcomes in patients with HF. They offer alternative treatment options for patients who are intolerant or continue to be symptomatic despite utilization of standard HF drug therapies at optimally tolerated dosages. A review of these 2 novel agents in HFrEF, including information on pivotal trials that led to its approval and its place in therapy for HFrEF, is presented.
Exposure of pharmacy students to postgraduate training prior to clinical practice is currently endorsed by national professional organizations. To meet this goal, colleges and schools of pharmacy are developing residency preparation programs. In this descriptive report, we review published studies of curricular activities and structured programs from academic institutions across the United States aimed at preparing students for residency training and promoting postgraduate education. Additionally, we discuss our experience developing a residency preparation program at Touro College of Pharmacy (TCOP).
A literature search yielded 15 residency preparation programs. While the format, content, and length of programs varied, there were common components such as curriculum vitae critique, mock interviews, and focused sessions on the residency application process. At TCOP, a 5-themed residency preparation workshop series was implemented during the third and fourth academic year. The workshops were modeled after existing programs and included several of the core components. One feature unique to the TCOP program was the addition of multiple mock interviews.
The growing focus on residency training has led to increased competition among applicants. To better prepare students for this rigorous application and interview process, development of structured residency preparation programs, similar to TCOP’s, should be encouraged.
Aflibercept is the most recently approved vascular endothelial growth factor (anti-VEGF) inhibitor for the management of diabetic macular edema and diabetic retinopathy. The purpose of this article is to review the efficacy and safety of aflibercept in the management of diabetic eye complications and to describe its place in therapy. Anti-VEGF agents have been noted in clinical trials to be superior to laser photocoagulation, the standard therapy (P < .0001, P ≤ .0085, respectively). Aflibercept has been comparatively studied with other anti-VEGF agents, namely, bevacizumab and ranibizumab, and noted to be equally efficacious and safe in patients with mild visual acuity loss (P > .50). However, in the treatment of patients with diabetic macular edema having moderate to severe visual acuity loss, aflibercept outperformed the other 2 anti-VEGF agents (aflibercept vs bevacizumab, P < .001; aflibercept vs ranibizumab, P = .003). However, additional studies are needed to fully appreciate the long-term safety and efficacy of aflibercept and the anti-VEGF therapy class.
Strong cytochrome P450 (CYP) 3A4 inhibitors may induce Cushing syndrome and subsequent adrenal insufficiency when administered concurrently with corticosteroids. This drug–drug interaction has been well described with HIV protease inhibitors. A similar drug–drug interaction with corticosteroids and other strong CYP 3A4 inhibitors (antifungals [imidazoles]) has recently been reported but remains less well known. To our knowledge, we report the first case of probable drug-induced Cushing syndrome with subsequent adrenal insufficiency as a result of concomitant oral voriconazole with intranasal mometasone and inhaled fluticasone administration as well as a review of the current literature supporting this drug–drug interaction.
This report describes a patient case utilizing a nontraditional sedative, continuous infusion ketamine, as an alternative agent for intensive care unit (ICU) sedation. A 27-year-old female presented for neurosurgical management of a coup contrecoup injury, left temporal fracture, epidural hemorrhage (EDH), and temporal contusion leading to sustained mechanical ventilation. The patient experienced profound agitation during mechanical ventilation and developed adverse effects with all traditional sedatives: benzodiazepines, dexmedetomidine, opioids, and propofol. Ketamine was titrated to effect and eliminated the need for other agents. This led to successful ventilator weaning, extubation, and transition of care. Given the unique side effect profile of ketamine, it is imperative that information is disseminated on potential utilization of this agent. More information is needed regarding dosing, monitoring, and long-term effects of utilizing ketamine as a continuous ICU sedative, but given the analgesia, anesthesia, and cardiopulmonary stability, future utilization of this medication for this indication seems promising.
Heart failure is associated with increased risk of morbidity and mortality, resulting in substantial health-care costs. Clinical pharmacists have an opportunity to reduce health-care costs and improve disease management as patients transition from inpatient to outpatient care by leading interventions to develop patient care plans, educate patients and clinicians, prevent adverse drug reactions, reconcile medications, monitor drug levels, and improve medication access and adherence. Through these methods, clinical pharmacists are able to reduce rates of hospitalization, readmission, and mortality. In addition, care by clinical pharmacists can improve dosing levels and adherence to guideline-directed therapies. A greater benefit in patient management occurs when clinical pharmacists collaborate with other members of the health-care team, emphasizing the importance of heart failure treatment by a multidisciplinary health-care team. Education is a key area in which clinical pharmacists can improve care of patients with heart failure and should not be limited to patients. Clinical pharmacists should provide education to all members of the health-care team and introduce them to new therapies that may further improve the management of heart failure. The objective of this review is to detail the numerous opportunities that clinical pharmacists have to improve the management of heart failure and reduce health-care costs as part of a multidisciplinary health-care team.
The frequency with which atypical antipsychotics initiated in the intensive care unit (ICU) is unknown. While there is lack of evidence to support the exact duration of treatment, antipsychotics should not be continued chronically for agitation and psychosis related to critical illness. The objective of this study was to determine whether atypical antipsychotics initiated in the ICU at a large tertiary academic medical center were continued after hospital discharge. Safety outcomes were also assessed.
A total of 1023 patients who received atypical antipsychotics during ICU stay were identified. Patients were assessed in a pseudo-randomized fashion until a sample of 191 patients was reached. After review of the exclusion criteria, the final study population was 100 patients. When antipsychotics were discontinued, progress notes were reviewed to identify the reason for discontinuation. Safety outcomes were assessed based on physician documentation in the medical charts.
Atypical antipsychotics were continued in 23% of patients. Atypical antipsychotics were discontinued in 1 patient due to QTc prolongation.
Atypical antipsychotics initiated in the ICU are frequently continued after hospital discharge. Given the known risks associated with extended therapy, initiatives are needed to prevent inappropriate continuation.
To summarize the literature on cholesterol point-of-care tests (POCTs). This article would serve as a resource to assist community pharmacists in developing cholesterol point-of-care (POC) pharmacy services.
A literature search was performed in MEDLINE Ovid, PubMed, EMBASE, and Cochrane database using the following medical subject headings (MeSH) terms: point-of-care test, cholesterol, blood chemical analysis, rapid testing, collaborative practice, community pharmacy, and ambulatory care. Additional resources including device manufacturer web sites were summarized to supplement the current literature.
All human research articles, review articles, meta-analyses, and abstracts published in English through September 1, 2014, were considered.
A total of 36 articles were applicable for review. Information was divided into the following categories to be summarized: devices, pharmacists’ impact, and operational cost for the pharmacy.
The current literature suggests that POCTs in community pharmacies assist with patient outcomes by providing screenings and referring patients with dyslipidemia for further evaluation. The majority of studies on cholesterol POC devices focused on accuracy, revealing the need for further studies to develop best practices and practice models with successful reimbursement. Accuracy, device specifications, required supplies, and patient preference should be considered when selecting a POC device for purchase.
To describe the development, implementation, and outcomes of a structured research training program that aimed to increase the research productivity among hospital pharmacists.
The program was conducted in a step-wise approach and started with educational sessions on evidence-based medicine and research methods. After about a year, pharmacists were trained and mentored on how to conduct and publish a research project. We evaluated the number of research projects and publications for the pharmacy department before and after the implementation of the program.
In the 5 years prior to implementing the program, there were a total of 4 institutional review board (IRB) proposals, 4 abstracts, and 2 manuscripts, which had pharmacists as primary investigators. After 5 years of running the program, there were 24 pharmacist-initiated research proposals submitted to the IRB, 29 abstracts, and 11 published manuscripts. The major challenges were the lack of sufficient time and the extensive training and mentorship required.
Implementing a structured pharmacy research program at a hospital setting was feasible and was associated with an increase in the pharmacist-led research and publications. The success of such a program requires training and mentorship, strong commitment, and administrative support.
Rabson-Mendenhall syndrome is a rare genetic disorder resulting from mutations in the insulin receptor and is associated with high degrees of insulin resistance. These patients are prone to complications secondary to their hyperglycemia including diabetic ketoacidosis (DKA). We report the case of a 19-year-old male with Rabson-Mendenhall syndrome presenting with DKA who required doses of up to 500 U/h (10.6 U/kg/h) of insulin. The patient’s insulin infusion was originally compounded with U-100 regular insulin, although to minimize volume, the product was compounded with U-500 insulin. The DKA eventually resolved requiring infusion rates ranging from 400 to 500 U/h. Although numerous opportunities for medication errors exist with the use of U-500 insulin, this case outlines the safe use of concentrated intravenous insulin when clinically indicated for patients requiring extremely high doses of insulin to control blood glucose.
The rates of venous thromboembolism (VTE) post-cardiothoracic surgery are not well understood. The american college of chest physicians (CHEST) guidelines report weak recommendations for starting VTE prophylaxis post-cardiothoracic surgery. It is suspected that due to the increase in bleed risk, postsurgery initiation of pharmacologic VTE prophylaxis is limited.
The study sought to investigate the use of VTE prevention in US hospitals performing cardiac surgery and the use of mechanical/chemical prophylaxis postoperatively.
This is a multicenter survey distributed to cardiac hospitals in the United States. The survey was distributed through 3 separate listservs. Data were analyzed utilizing descriptive statistics.
The majority of the hospitals were academic and/or community and completed coronary artery bypass graft (CABG), valve replacement (mitral/aortic/tricuspid), and aortic repair. It was common for hospitals to start mechanical and pharmacologic prophylaxis post-cardiothoracic surgery on postoperative day (POD) 1 to 2. The anticoagulation most commonly used consisted of unfractionated heparin.
The majority of the institutions are initiating therapy POD 1 to 2 with both mechanical and chemical prophylaxis. The full impact of early initiation of VTE prophylaxis is unknown, and more studies are needed to assess the true risks/benefits of these practices.
Funguria occurs often in hospitalized patients and is most commonly caused by Candida species. Fluconazole is the agent of choice for most Candida urinary tract infections. Amphotericin B bladder irrigations (ABBI) are an alternative treatment option.
The purpose of this study is to assess the efficacy of ABBI compared to fluconazole for the treatment of candiduria in the intensive care unit (ICU) setting.
We conducted a retrospective chart review of patients admitted to ICUs at our institution with a positive urine culture for Candida species between 2005 and 2012. All patients receiving ABBI were included; patients receiving fluconazole for treatment of candiduria were matched by year. The primary endpoint was achievement of cure.
There was no difference in cure between the ABBI and fluconazole groups (59.6% vs. 52.8%, p = 0.55). Clearance was higher in patients receiving ABBI (92.3% vs. 67.9%, p < 0.001). Logistic regression found that renal dysfunction predicted greater cure with ABBI therapy compared to fluconazole (OR 7.63, 95% CI 1.81-32.1).
ABBI was equally efficacious in achieving overall cure, and resulted in greater clearance of candiduria compared to fluconazole. ABBI may be considered an alternative to fluconazole for the treatment of candiduria and may be preferred over fluconazole in patients with renal dysfunction.
The Ambulatory Cardiac Triage, Intervention, and Education (ACTIVE) infusion unit is an outpatient center that aims to provide heart failure (HF) patients with comprehensive multidisciplinary interventions.
To describe the patient population served in ACTIVE and to document the prevalence of comorbidities and drug therapy-related issues (DRIs) in order to define the most effective role of a pharmacist in the unit.
Patients who have been interviewed by a pharmacist in ACTIVE were included. Comprehensive medical and medication profile reviews were performed. Patient comorbidities were documented, and DRIs were classified.
Sixty patients were included. Most prevalent cardiac comorbidities included hypertension (73%) and hyperlipidemia (62%). Top 3 noncardiac comorbidities included chronic kidney disease (60%), diabetes (50%), and obesity (35%). The prevalence of DRI was reported as follows: (1) needs additional/alternative therapy (untreated indication [37] or suboptimal therapeutic choice [46]), (2) wrong drug (major drug–drug interaction [90], contraindication [11], or duplicate therapy [1]), (3) suboptimal dosing (17), (4) dose exceeds recommended maximum (9), and (5) adverse drug reaction (93). In 63 (22%) of the DRIs, a pharmacist made recommendations to modify the regimen.
The prevalence of DRI is high even among HF patients managed in a subspecialty cardiovascular practice. Pharmacists in this setting play a vital role in more effectively resolving DRI.
To determine whether there is an association between higher vancomycin trough concentrations and attainment of a calculated area under the concentration–time curve (AUC)/minimum inhibitory concentration (MIC) ≥400.
A retrospective analysis was conducted among vancomycin-treated adult patients with a positive methicillin-resistant Staphylococcus aureus (MRSA) culture. Attainment of a calculated AUC/MIC ≥400 was compared between patients with troughs in the reference range of 15 to 20 mg/L and those with troughs in the following ranges: <10, 10 to 14.9, and >20 mg/L. Nephrotoxicity was assessed as a secondary outcome based on corrected average vancomycin troughs over 10 days of treatment.
Overall, 226 patients were reviewed and 100 included. Relative to troughs ≥10, patients with vancomycin troughs <10 mg/L were 73% less likely to attain an AUC/MIC ≥400 (odds ratio [OR] 0.27, 95% confidence interval [CI]: 0.01-0.75). No difference was found in the attainment of an AUC/MIC ≥400 in patients with troughs of 10 to 14.9 mg/L and >20 mg/L when compared to patients with troughs of 15 to 20 mg/L. The mean corrected average vancomycin trough was higher in patients developing nephrotoxicity compared to those who did not (19.5 vs 14.5 mg/L, P < .001).
Achieving vancomycin serum trough concentrations of 15 to 20 mg/L did not result in an increased attainment of the AUC/MIC target relative to troughs of 10 to 14.9 mg/L but may increase nephrotoxicity risk.
To report on a patient with a symptomatic, polymicrobial Escherichia coli and multidrug-resistant (MDR), extended-spectrum β-lactamase (ESBL)-positive Klebsiella pneumoniae urinary tract infection (UTI) who was successfully treated with oral doxycycline hyclate.
A 70-year-old white male inpatient with a history of recurrent UTI, type 2 diabetes, hypertension, obesity, and diverticular disease was diagnosed with UTI and empirically treated with oral ciprofloxacin. Symptoms persisted 2 days later, and the patient was transitioned to amoxicillin/clavulanate by a different provider. The next day, upon receipt of the urine culture and susceptibility panel revealing E coli and MDR, ESBL-positive K pneumoniae infection, treatment was switched to doxycycline hyclate, which resulted in clinical improvement.
Complicated UTI involving multiple pathogens requires careful clinical judgment to select the appropriate antimicrobial agent, improve clinical outcomes, and prevent resistance. Treatment with doxycycline was based on the susceptibility panel and local resistance patterns. Advantages of doxycycline for UTI include its oral formulation, wide spectrum of activity, ability to achieve high concentration in the urine, and low toxicity.
Doxycycline hyclate may be an effective treatment option for patients with susceptible MDR UTI.
Dosing of intravenous acyclovir for herpes encephalitis in obese patients is recommended to be based on ideal body weight. However, limited data support this recommendation, and recent data suggest this may lead to underdosing.
To determine national dosing practices of intravenous acyclovir across a range of patient weights.
A survey was distributed to members of the American College of Clinical Pharmacy Critical Care and Infectious Diseases Practice & Research Networks listservs. Data collected included demographic information and dosing of acyclovir, given consistent patient cases with varying patient weight.
A total of 264 pharmacists participated in the survey, with 240 (90.9%) participants completing the survey. Participants were predominately clinical pharmacists. As patient weight increased, respondents were more apt to dose based on an adjusted body weight, with dosing in the obese and morbidly obese showing a clear lack of consistency.
Intravenous dosing of acyclovir for herpes encephalitis is variable, especially in obese patients, and does not reflect recommendations. Limited data provide conflicting recommendations for dosing in obese patients, and future studies are necessary to optimize patient outcomes and prevent toxicity.
Since its isolation in the 1930s, digoxin has played a pivotal role in the treatment of cardiac conditions including heart failure and supraventricular tachyarrhythmias. The parasympathomimetic activity makes digoxin a reasonable option for controlling ventricular rate in atrial fibrillation (AF). However, the unique pharmacokinetic properties, electrolyte-dependent effects, and P-glycoprotein drug interactions influence the clinical use of digoxin. In addition, the delayed onset and narrow therapeutic index can make digoxin utilization cumbersome and often necessitates serum drug monitoring. Despite digoxin’s extensive history, recent literature has cast doubt on the efficacy and safety of this medication in the population with AF. Large amounts of data suggest digoxin offers no benefit on mortality and may increase the risk of mortality though this was not consistent in all evaluations. While robust, the majority of the available studies are not randomized which limits the ability to draw firm conclusions. The potential risk of mortality must be weighed against the expected benefits of digoxin use to make individualized patient care decisions. Clinicians should refrain from utilizing digoxin monotherapy for rate control in AF when other options are viable.
The use of vancomycin is common among hospitalized children. We sought to evaluate the impact of prospective audit with real-time feedback on vancomycin use and pharmacy costs.
Vancomycin use was evaluated at Monroe Carell Jr Children’s Hospital at Vanderbilt (MCJCHV) before and after the implementation of prospective audit with intervention and feedback to providers in 2012. Antibiotic use was compared to academic children’s hospitals with established antimicrobial stewardship programs (ASPs). Two similar pediatric academic institutions without an ASP were used as nonintervention controls. Analysis of monthly days of antibiotic therapy (DoT) per 1000 patient-days was performed by interrupted time series analysis.
Monthly vancomycin use decreased from 114 DoTs/1000 patient-days to 89 DoTs/1000 patient-days (P < .0001). We did not find significant differences in the slope of change in vancomycin use between MCJCHV and institutions with ASPs either before or after the intervention (P = .86 and P = .71, respectively). When compared to children’s hospitals without ASPs, the use of vancomycin was significantly lower at MCJCHV (P < .001).
The use of vancomycin at academic children’s hospitals with an ASP is declining. In our experience, prospective audit with real-time intervention and feedback to providers significantly reduced the use and costs associated with vancomycin.
Pharmacologic agents for the treatment and prevention of venous thromboembolism in the cancer patient population are limited. Currently, low-molecular-weight heparin is recommended by national consensus guidelines for this indication. Rivaroxaban, an oral factor Xa inhibitor, is Food and Drug Administration (FDA) approved for the treatment and prevention of venous thromboembolism and offers the convenience of oral fixed-dose regimens, no routine laboratory monitoring, and has few drug and dietary interactions; however, its use in patients with cancer has not been largely studied. We report 2 cases of recurrent venous thromboembolism in patients with active cancer on rivaroxaban therapy. The first case is a 64-year-old female admitted for recurrent pulmonary embolism, and the second case is a 70-year-old female admitted for recurrent deep vein thrombosis. Both patients were receiving rivaroxaban at the time of thromboembolic recurrence. These cases serve as a reminder to health-care providers that more safety and efficacy data in the cancer patient population are needed prior to using rivaroxaban for venous thromboembolism treatment.
Study goal was to assess the impact of the 2013 American College of Cardiology and the American Heart Association (ACC/AHA) Cholesterol Guidelines on patients in the fourth statin benefit group which included patients aged 40 to 75 years, without diabetes or clinical atherosclerotic cardiovascular disease (ASCVD), and have an ASCVD score ≥7.5%. These patients could benefit from treatment interventions by a pharmacist.
Patients were identified from electronic health records. A sample of 3503 patients was ascertained from having a lipid panel performed within the 12 months before November 1, 2013. Patients were excluded if we were unable to calculate 10-year ASCVD risk.
A total of 3203 patients were included, with 2008 not on statin therapy. Of those, 1507 (75%) had a 10-year ASCVD risk score <7.5% and 501 (25%) had a score
Widespread adoption of the 2013 ACC/AHA Cholesterol Guidelines will expand prescribing rates of statins. Implementing screening strategies may help identify patients who require treatment in this fourth statin benefit group. A pharmacist can be vital in screening patients, educating patients regarding the need for medication therapy, and monitoring for adherence in these new regimens.
Fluoroquinolones are extensively used to treat a variety of common bacterial infections. Due to their extensive use in clinical practice, increases in neuropsychiatric events have been reported. We discuss the case of a young female who developed visual hallucinations after 2 doses of moxifloxacin. After discontinuation of the moxifloxacin, the patient’s symptoms completely resolved. While one other case report exists with moxifloxacin, this case is unique in comparison. Our patient was a young female with no kidney dysfunction, no drug abuse history, absence of polypharmacy, and no previous psychological history that would have put her at an increased risk of drug-induced psychosis. Due to the prevalence of medication-induced hallucinations, it is imperative that clinicians are able to recognize offending medications in an effort to prevent misdiagnosis of a psychiatric illness.
Dual antiplatelet therapy (DAPT) is the key for secondary prevention of acute coronary syndromes and percutaneous coronary intervention with stent placement. Premature discontinuation of DAPT can result in an increase in cardiac ischemic events and death. If early interruption of DAPT for urgent procedures or surgery is necessary, then ischemic and bleed risks must be balanced with bridging therapy. To date, no medications have a Food and Drug Administration indication for antiplatelet bridge therapy. We present a case of a woman with a history of gastrointestinal bleeding on DAPT for a drug-eluting stent who received cangrelor as bridge therapy prior to gastroduodenal biopsy.
Hospital readmissions have recently gained scrutiny by health systems as a result of their high costs of care and potential for financial penalty in hospital reimbursement. Mobile-integrated health and community paramedicine (MIH-CP) programs have expanded to serve patients at high risk of hospital readmission. Pharmacists have also improved clinical outcomes for patients during in-home visits. However, pharmacists working with a MIH-CP program have not been previously described. This project utilized a novel multidisciplinary Community Paramedicine Team (CPT) consisting of a pharmacist, paramedic, and social worker to target patients with heart failure at high risk of readmission to assist with coordination of care and education.
This article describes the development of the CPT, delineation of CPT member responsibilities, and outcomes from pilot visits.
The CPT visited eligible patients in their homes to provide services. Patients with heart failure who were readmitted within 30 days were eligible for a home visit.
A total of 6 patients were seen during the pilot, and 2 additional patients were seen after the pilot.
Imbedding a pharmacist into a CPT provides a unique expansion of pharmacy services and a novel approach to address hospital readmissions.
A palliative care knowledge survey was conducted involving pharmacy students to examine their perceived usefulness and the educational effect of clinical training in hospitals.
A questionnaire sheet was distributed to fifth-year pharmacy students before and after clinical training. The questionnaire consisted of questions to clarify the details of palliative care-related training in hospitals and students’ knowledge of such care. The respondents were divided into 2 groups: those who participated in palliative care team (PCT) rounds (group A: 57) and those who did not (group B: 57).
The mean total correct answer rate markedly increased after training in group A, from 37.9 to 47.1% (P < .01). Such an increase was also observed in the domains of philosophy and pain in this group (P < .01). In contrast, group B did not show differences in the mean correct answer rate between before and after training; there was no significant increase in the rate in any domain.
Pharmacy students’ knowledge was enhanced by participating in the PCT, confirming the usefulness of such participation during training as part of palliative care education.
Bacillus Calmette-Guérin (BCG) is a live, attenuated strain of Mycobacterium bovis that is used to treat superficial bladder cancer. Although its use is typically associated with only mild, localized side effects, rare systemic complications can occur. Disseminated mycobacterium infections after BCG therapy have been reported in over 30 cases; however, central nervous system (CNS) infections do not commonly occur. We report a 74-year-old male who developed a M. bovis cerebellar abscess after receiving intravesical BCG infusion for bladder cancer for less than 1 year. This patient was successfully treated with antituberculosis therapy and corticosteroids. This patient case demonstrates that early-onset M bovis CNS infections can occur after BCG therapy. Patients presenting with altered mental status while on BCG therapy should be evaluated for disseminated infections.
To determine the incidence and severity of bleeding events requiring hospitalization among patients with atrial fibrillation (AF) receiving anticoagulants (dabigatran or warfarin) or antiplatelet agents (eg, aspirin and clopidogrel).
This was a single-center, retrospective cohort study involving 1494 patients with AF hospitalized from November 1, 2010, to November 1, 2011, with prior warfarin, dabigatran, or antiplatelet therapy.
Overall bleeding events in the dabigatran group compared to the warfarin group were 24% and 12%, respectively (P = .004). Of these events, individually, there were no significant differences in major (56% vs 58%, P = .88), life-threatening (25% vs 36%, P = .38), or minor bleeding (44% vs 42%, P = .06). Gastrointestinal (GI) bleeding occurred more in the dabigatran group compared to the warfarin group (P = .02). Intracranial bleeding occurred in 15% of patients in the warfarin group and did not occur at all in the dabigatran group. Warfarin patients had significantly more overall bleeding events compared to antiplatelet therapy (P < .001), with an increasing trend seen in major bleeding (P = .06). GI bleeding, however, favored the warfarin group over the antiplatelet group (48% vs 73%, P = .04).
Anticoagulation with dabigatran was associated with an overall increased occurrence of bleeding requiring hospital admission compared to warfarin. GI bleeding was more prevalent with dabigatran and antiplatelets than with warfarin. There were more intracranial hemorrhages seen in the warfarin group.
To evaluate whether clinical data support the safety and efficacy of probiotics for the management of infantile colic.
Probiotics have been suggested as a potential strategy for infantile colic, and the specific species that have been studied in healthy infants are considered to be safe.
A systematic review was conducted to identify randomized controlled trials (RCTs) evaluating the use of probiotic supplementation in infants with colic. RCTs with a primary end point assessing crying or fussing time were selected. A meta-analysis comparing "responders" to "nonresponders" in infants receiving probiotic versus control was conducted. The quality of trials selected was assessed.
Five RCTs assessing 2 different strains of the probiotic Lactobacillus reuteri in mostly breastfed infants were identified. Analysis of response rates showed that infants receiving probiotics had a 2.3-fold greater chance of having a 50% or greater decrease in crying/fussing time compared to controls (P = .01). Probiotic supplementation was not associated with any adverse events.
Supplementation with the probiotic L. reuteri in breastfed infants appears to be safe and effective for the management of infantile colic. Further research is needed to determine the role of probiotics in infants who are formula-fed.
The study investigated the level of adherence and factors affecting adherence to antiretroviral treatment (ART).
The study sample consisted of 300 HIV-infected patients who received ART in the Antiretroviral Clinic of Central Hospital, Agbor, Delta State, Nigeria. Self-reported adherence to ART in the previous 1 month prior to the study as well as determinants of adherence were assessed using a questionnaire.
The most frequently used ART regimen was zidovudine + lamivudine + nevirapine. On the whole, a total of 33 (11%) respondents missed 3 doses or less in the previous month prior to the survey. There was a statistically significant association between adherence to ART and marital status, source of income, and occupation (P < .05). The most commonly reported reasons for missed doses were forgetfulness (60.4%), busy daily task (18.3%), and avoiding being seen while taking medications (11%).
The prevalence of adherence among the participants was high. However, more serious efforts are needed to reduce the number of in-adherent patients. Interventions to improve adherence to ART should address challenges such as forgetfulness among the patients and frequent occurrence of adverse effects and consider specific patient-related factors such as daily tasks.
To prospectively evaluate the observed incidence of acute kidney injury (AKI) in adult patients receiving the combination of piperacillin-tazobactam and vancomycin versus the combination of cefepime or meropenem and vancomycin for greater than 72 hours.
This was a prospective, open-label cohort study at a community academic medical center involving adult patients over a 3-month time period who received either the combination of piperacillin-tazobactam and vancomycin or the combination of cefepime or meropenem and vancomycin for greater than 72 hours. The patients were evaluated for AKI, defined using specific criteria introduced by Kidney Disease: Improving global outcomes (KDIGO) acute kidney injury work group in 2012.
A total of 85 patients receiving either antimicrobial combination were evaluated for AKI. The incidence of AKI was significantly higher in the piperacillin-tazobactam and vancomycin group (37.3%) compared with the cefepime or meropenem and vancomycin group (7.7%; 2 = 7.80, P = .005).
The result of this study suggests that the risk of developing AKI is increased in patients receiving the combination of piperacillin-tazobactam and vancomycin versus those receiving the combination of cefepime or meropenem and vancomycin.
To compare the effectiveness of 4 different instructional interventions in training proper inhaler technique.
Randomized, noncrossover trial. Setting: Health fair and indigent clinic.
Inhaler-naive adult volunteers who spoke and read English.
Subjects were assigned to complete the following: (1) read a metered dose inhaler (MDI) package insert pamphlet, (2) watch a Centers for Disease Control and Prevention (CDC) video demonstrating MDI technique, (3) watch a YouTube video demonstrating MDI technique, or (4) receive direct instruction of MDI technique from a pharmacist.
Inhaler use competency (completion of all 7 prespecified critical steps).
Of the 72 subjects, 21 (29.2%) demonstrated competent inhaler technique. A statistically significant difference between pharmacist direct instruction and the remaining interventions, both combined (P < .0001) and individually (P ≤ .03), was evident. No statistically significant difference was detected among the remaining 3 intervention groups. Critical steps most frequently omitted or improperly performed were exhaling before inhalation and holding of breath after inhalation.
A 2-minute pharmacist counseling session is more effective than other interventions in successfully educating patients on proper inhaler technique. Pharmacists can play a pivotal role in reducing the implications of improper inhaler use.
Different strategies have been implemented to assist students in securing residency positions. The purpose of this study was to explore the impact of student participation in residency preparation activities on match rates.
A retrospective observational study was conducted to explore the effect of participation in residency preparation activities and grade point average (GPA) on residency match rate. Match rates for students participating in the Residency Interview Preparation Seminar (RIPS) or mock interviews (ie, intervention group) were compared with students who participated in neither activity (ie, control group).
A total of 118 individuals were included in the comparison. Forty-eight students participated in RIPS (n = 29) or mock interviews (n = 19), while 70 students were in the control group. The intervention group had a statistically larger proportion of students securing residency than the control group (81% vs 57%; P = .009). Match rates between students enrolled in RIPS versus those in the mock interview group were not significant. No statistically significant differences were observed based on GPA.
Students receiving additional preparation prior to interviews when seeking postdoctoral training were significantly more likely to obtain a residency position. In academic settings with limited resources, mock interviews may be preferred over comprehensive preparatory courses.
Due to the intimate relationship between liver and kidney disease in hepatitis C virus (HCV) infection, treatment options for HCV-positive patients at any stage of chronic kidney disease (CKD) are essential. The availability of second-generation, direct-acting antiviral (DAA) combinations has allowed for the advent of interferon-sparing treatment regimens with shorter durations and minimal side effects. While many of the second-generation DAAs are principally metabolized by the hepatic system, dosing in severe renal impairment (creatinine clearance [CrCl] <30 mL/min) or dialysis has remained questionable due to limited experience. New evidence regarding the use of these agents in renal impairment continues to become available, as real-world experience with these treatment regimens is reported. Simeprevir, ledipasvir, paritaprevir, ombitasvir, dasabuvir, and daclatasvir have data to suggest safety in end-stage renal disease. While safety and efficacy with sofosbuvir remains uncertain, data are now available to support utilizing a dose adjustment when glomerular filtration rates are <30 mL/min. Upcoming regimens grazoprevir/elbasvir and daclatasvir/asunaprevir/beclavubir may provide further options for patients with advanced kidney disease, and ongoing studies will continue to provide guidance for this unique patient population. This article will review the currently available literature, including the newest emerging evidence, on the use of second-generation DAAs in CKD stages 3 to 5 and dialysis.
The national initiative, Project IMProving America’s Communities Together (IMPACT): Diabetes, was intended to scale a proven American Pharmacists Association (APhA) Foundation process model, which integrates pharmacists on the collaborative health-care team, in communities greatly affected by diabetes to improve key indicators of diabetes. This article discusses the results from 1 community in Mississippi.
This national prospective study followed patients with a hemoglobin A1c (HbA1c) >7% from September 2011 to January 2013. Pharmacists collaborated with providers and other health-care professionals to provide medication therapy management services for a minimum of 3 visits. Outcome measures included HbA1c, systolic and diastolic blood pressure (SBP and DBP), fasting cholesterol panel, body mass index (BMI), influenza vaccine and smoking status, and foot and eye examination dates.
At this site, there were statistically significant outcomes including mean HbA1c decrease of 1.2% in SBP and DBP of 8.3 mm Hg and 3.5 mm Hg, respectively, and reduction in low-density lipoprotein of 16.6 mg/dL, all of which were greater improvements compared to overall results from combined sites.
Patients in this community who received care from the collaborative team, including a pharmacist, had improvement in most key indicators of diabetes, with a clinically significant reduction in HbA1c.
To compare the return on investment (ROI) of an integrated practice model versus a "hub and spoke" practice model of pharmacist provided medication therapy management (MTM).
A cohort retrospective analysis of MTM claims billed in 76 pharmacies in North Carolina in the 2010 hub and spoke practice model and the 2012 "integrated" practice model were analyzed to calculate the ROI.
In 2010, 4089 patients received an MTM resulting in 8757 claims in the hub and spoke model. In 2012, 4896 patients received an MTM resulting in 13 730 claims in the integrated model. In 2010, US$165 897.26 was invested in pharmacist salary and $173 498.00 was received in reimbursement, resulting in an ROI of +US$7600.74 (+4.6%). In 2012, US$280 890.09 was invested in pharmacist salary and US$302 963 was received in reimbursement, resulting in an ROI of +US$22 072.91 or (+7.9%).
The integrated model of MTM showed an increase in number of claims submitted and in number of patients receiving MTM services, ultimately resulting in a higher ROI. While a higher ROI was evident in the integrated model, both models resulted in positive ROI (1:12-1:21), highlighting that MTM programs can be cost effective with different strategies of execution.
To detail the implementation of a pharmacist-driven education program targeting patients who originally declined pneumococcal or influenza vaccination upon hospital admission and to evaluate the results.
Patients admitted to a small community hospital who qualified to receive pneumococcal polysaccharide or influenza vaccination but declined upon admission were educated in person by pharmacists or pharmacy interns and reoffered vaccination. Patient education sheets were provided. Data were obtained via pharmacy intervention documentation in the pharmacy order entry system. Staff documented the outcome of counseling for each patient.
A total of 214 and 83 patients receiving influenza and pneumococcal vaccination counseling, respectively, were evaluated. As a result, 23.4% (P = .06) and 26.5% (n = 83, P = .18) of patients agreed to receive influenza and pneumococcal vaccines, respectively. An unanticipated subset of patients were undecided after counseling and wanted to consider the information further before making a final decision. Taken together with those who consented to receive the vaccine after counseling, 39.2% (P = .001) and 45.8% (P = .01) of patients were influenced by the influenza and pneumococcal vaccination counseling, respectively.
Patient education performed by a pharmacist or pharmacy intern showed a trend toward increased pneumococcal and influenza vaccination acceptance rates for inpatients who had initially declined.
The purpose of this article is to review the safety, efficacy, and role of efinaconazole and tavaborole in the treatment of onychomycosis.
Onychomycosis is a fungal infection of the nail caused by dermatophytes, yeasts, and nondermatophyte fungi. Distal and lateral subungual onychomycosis (DLSO) accounts for the majority of the cases. These infections cause structural damage to the nail which makes treatment difficult. Both oral and topical agents exist for the treatment of onychomycosis. Oral medications have generally been more effective, yet adverse effects and drug interactions limit their use in some patients. Food and Drug Administration (FDA)-approved agents in the United States for oral therapies include terbinafine, itraconazole, and griseofulvin. The only topical product available up to recently was ciclopirox.
This article will review efinaconazole and tavaborole, 2 new topical antifungal agents released in 2014.
To review pivotal clinical trials, pharmacology, contraindications, precautions, and key patient education points of flibanserin for the treatment of hypoactive sexual desire disorder (HSDD) in premenopausal women.
A literature search of PubMed using the key words flibanserin and HSDD was conducted in September 2015. There was no time frame to exclude relevant clinical trials. All trials referenced were published between March 2012 and June 2014. Other relevant information was obtained from the Food and Drug Administration (FDA) Web site, press releases, prescribing information from the manufacturer, and ClinicalTrials.gov.
All articles in the English language and involving human subjects were reviewed.
There are three 24-week, multicenter, randomized, double-blind, placebo-controlled trials that evaluated the efficacy of flibanserin in North American premenopausal women with HSDD. There was 1 trial that studied the effects of flibanserin in postmenopausal women. In all of the trials, the investigators found statistical significant improvements in Female Sexual Function Index (FSFI) desire domain score and satisfying sexual events (SSEs). The most frequently reported adverse events in all flibanserin arms of treatment were somnolence, dizziness, and nausea.
Flibanserin, a novel, nonhormonal agent that modulates excitatory and inhibitory neurotransmitters was studied in premenopausal women and has shown efficacy in improving sexual desire and SSEs.
Lichen planus (LP) is a mucocutaneous inflammatory disease that involves papulosquamous eruption of the skin, scalp, nails, and mucous membranes. This uncommon condition has a higher prevalence in African Americans and females. Women accounts for 50% of cutaneous LP (CLP) and 60% to 75% of oral LP (OLP) cases. Diagnosis is centered around clinical presentation. Patient evaluation requires a comprehensive physical examination to identify any potential sites of involvement. LP is usually described by the "Six P’s": planar, purple, polygonal, pruritic, papules, and plaques. Drug-induced LP, or lichenoid drug reactions, is uncommon and usually indiscernible from other forms of LP. Lichenoid drug reactions exhibit parakeratosis, dermal infiltrates of eosinophils, or perivascular lymphocytic infiltrates affecting the reticular dermis. An extended time interval between the initiation of drug to the onset of symptoms usually does not exclude potential diagnosis of a lichenoid drug reaction. We describe a case of hydrochlorothiazide-induced LP without prolonged exposure to sunlight diagnosed in the emergency department (ED). In this case, a pharmacist-conducted medication reconciliation played an integral role in accurately recognizing this adverse drug reaction. Our case report adds to the limited available literature on the topic, most of which originated more than 30 years ago.
We describe the first successful case of posaconazole salvage therapy for mucormycosis with concomitant sirolimus (SRL) maintenance immunosuppression following liver transplantation, despite black box drug interaction following intolerance to first-line tacrolimus and amphotericin due to nephrotoxicity and neurotoxicity. This case describes a 55-year-old female who developed rhinocerebral mucormycosis 108 days after liver transplantation. After 3 months of posaconazole therapy, the patient remains free of disease at 3 years posttransplant. This case report illustrates successful resolution of mucormycosis without SRL toxicity to resolve nephrotoxicity of long-term amphotericin on top of already nephrotoxic immunosuppression. With higher bioavailability of recently FDA-approved posaconazole delayed release tablets, this azole may be a therapeutic option for transplant patients who need to remain on CYP3A4-metabolized immunosuppressive agents.
To report a case of dysgeusia and dysosmia following midodrine initiation.
A 58-year-old male started midodrine 5 mg tablets 3 times a day for orthostatic hypotension. Two weeks after starting, he began complaining of dysgeusia and dysosmia. He also reported less of an appetite at this time but did not realize it was due to symptoms. He reported his symptoms as tolerable and chose to continue the medicine. At follow-up contact 7 days later, the symptoms were still present but diminishing.
Midodrine is used for symptoms of orthostatic hypotension. Dysgeusia and dysosmia are not common adverse events and are not included in the manufacturer’s labeling. There is only one other published case report of this reaction. Our patient only admitted to slight appetite suppression, but it may be more profound in some. The reaction may be dose related, but there is not enough information to make this conclusion.
Using midodrine may result in dysgeusia and dysosmia. According to this case, both adverse effects may lessen or resolve over time with the use of the medication.
To evaluate whether statin use influences gastrointestinal cancer prognosis in patients with diabetes mellitus (DM).
We reviewed all DM patients diagnosed at Roswell Park Cancer Institute with emergent gastrointestinal malignancy (January 2003 to December 2010) (N = 222). Baseline demographic, clinical history, and cancer outcomes were documented. Overall survival (OS) and disease-free survival (DFS) comparisons across various treatment groups were assessed by Kaplan-Meier and Cox proportional hazards.
Use of statin, alone or in combination, was associated with improved OS and DFS (hazard ratio [HR] = 0.65, P = .06; HR = 0.60, P < .02). We report similar OS and DFS advantage among users of mono- or combined metformin therapy (HR = 0.55, P < .01; HR = 0.63, P < .02). Concomitant use of metformin and statin provided a synergistic OS and DFS benefit (HR = 0.42, P < .01; HR = 0.44, P < .01). Despite significant tobacco and alcohol use history, patients with upper gastrointestinal cancers derived enhanced cancer outcomes from this combination (HR = 0.34, P < .01; HR = 0.43, P < .02), while receiving a statin without metformin or metformin without a statin did not provide significant cancer-related benefits.
Use of statin and metformin provides a synergistic improvement in gastrointestinal malignancies outcomes.
Nutritional protein may decrease levodopa absorption and has resulted in withdrawal and neuroleptic malignant-like syndromes in critically ill patients. A 72-year-old male was admitted with shortness of breath. His medical history included Parkinson’s disease for over 30 years for which he took carbidopa/levodopa 5 times daily. The patient’s home medications were continued. On day 2, he was intubated and transferred to the intensive care unit (ICU). He was extubated the next day and reintubated on day 4. Enteral nutrition was initiated at 85 mL/h overnight. The patient’s carbidopa/levodopa was administered to limit coadministration with nutrition. Throughout his ICU stay, the patient did not demonstrate changes in mental status. Despite resolution of his pneumonia, he developed fever after administration of one dose overlapping with nutrition, with defervescence throughout the rest of the day. On hospital day 10, that dose was empirically increased. After this dosing change, the patient failed to develop fever during the rest of his hospital stay. On day 16, the patient was discharged to a long-term care facility without any other complications. Our case highlights the interaction between levodopa and enteral nutrition and the potential of fever as the sole sign of withdrawal.
Phototherapy recall can occur unexpectedly as a result of treatment with commonly used medications and chemotherapy. These reactions are rare. The recall reaction is an inflammatory response that is triggered by many medications. Cyclophosphamide and docetaxel are widely used chemotherapeutic agents that are useful in the management of many different malignancies. The pathophysiology of phototherapy recall is not clearly understood. This case highlights the need for practitioners to be aware of this potential reaction, even though UV exposure may have occurred in the distant past. We present, to the best of our knowledge, the first phototherapy recall dermatitis that occurred years after UV exposure induced by cyclophosphamide and docetaxel. The frequency of administration of this drug and the profound implications of this adverse effect make this case an important contribution to the medical literature.
Despite the increasing importance placed on advanced training for clinical pharmacists, literature describing postgraduate year 2 (PGY2) residency opportunities is limited. The objective of this study was to describe characteristics of PGY2 programs within the Veterans Affairs (VA) healthcare system.
An online survey addressing attributes of PGY2 residency programs was electronically distributed to VA residency program directors (RPDs).
Responses from 27 (32.9%) VA PGY2 residency programs were included, representing 11 distinct PGY2 specialties. Growth and recruitment trends were similar across programs, with most programs projecting additional expansion. Staffing requirements were uncommon, but opportunities to precept and earn teaching certificates were prevalent. RPDs had been licensed pharmacists an average of 16.9 years, and most had at least 1 advanced certification. The majority of programs had a formal residency advisory committee and required preceptors to attend regular development meetings.
Although multiple postgraduate specialties were represented, the requirements and opportunities available for PGY2 pharmacy residents were similar across VA facilities. By comparing residency programs in a nationally integrated health-care system, this study may promote growth of existing PGY2 programs, facilitate the establishment of new programs, and provide a framework for prospective residents to evaluate programs of interest.
To compare between weekly and daily cholecalciferol in patients with hypovitaminosis D and to determine the optimal maintenance dose.
Seventy-one volunteers with hypovitaminosis D were randomly assigned to 2 dose regimens: cholecalciferol 50 000 IU weekly for 8 weeks, then 50 000 IU monthly for 2 months (group A) and 7000 IU daily for 8 weeks, then 12 500 IU weekly for 2 months (group B). Cholecalciferol was stopped for 2 months and reintroduced as 50 000 IU bimonthly for group A and 50 000 IU monthly for group B.
Two months after therapy, the mean serum 25-hydroxyvitamin D (25(OH)D) level increased from 11.4 to 51.2 ng/mL and from 11.7 to 44.9 ng/mL in groups A and B, respectively (P = .065). The levels of 25(OH)D declined similarly in both groups during maintenance and after holding therapy. After resuming cholecalciferol, 25(OH)D levels increased to 33.8 and 28.8 ng/mL in groups A and B, respectively (P = .027). There was a negative correlation between serum 25(OH)D levels and body mass index (BMI; P = .040).
Timing and frequency of the dosing (daily vs weekly) have no effect on the rise in serum 25(OH)D levels as long as the accumulative dose of cholecalciferol is similar. Cholecalciferol 50 000 IU bimonthly is required to maintain sufficient 25(OH)D levels.
The overuse of antibiotics in the community is a primary cause of antibiotic resistance. Community pharmacists are the most accessible health professionals and so they are in an ideal position to implement interventions to ensure the appropriate use of antibiotics. This study aimed to explore the role of community pharmacists in the optimization of antibiotic prescribing and utilization.
Four focus groups were conducted with community pharmacists in Perth, Western Australia. Audio-recorded data were compared with field notes, transcribed, and thematically analyzed.
There were twenty-four participants in four focus group sessions. Four main themes were identified: patient perceptions and behaviors, prescribing behaviors, pharmacists’ roles and responsibilities, and health care system interventions in relation to antibiotic utilization. A number of interventions that could be implemented by community pharmacists were identified. In addition to interventions that are currently in place in Australia, forward dispensing, improved interprofessional collaboration, an expansion of current prescribing role, and vaccination capabilities were also suggested.
This study indicated that current scope of pharmacists’ roles has room for more intervention strategies aimed at improving antibiotic prescribing and utilization in the community.
The hepatitis C virus (HCV) is the most common chronic blood-borne infection and the leading cause of liver transplantation in the United States. There are approximately 3.2 million people currently infected with HCV in the United States. In late 2013, the introduction of sofosbuvir and simeprevir represented a critical advancement in the treatment of HCV by improving sustained virologic response (SVR) rates.
The purpose of this study was to evaluate medication utilization and clinical outcomes of patients with HCV who were treated with any Food and Drug Administration-approved combination of ribavirin, peginterferon products, simeprevir, and sofosbuvir.
Prescription records and clinical assessment forms of patients who started HCV therapy and were eligible for SVR between January 1, 2014, and December 31, 2014, were retrospectively reviewed. Data collection included patient demographics, genotype, SVR, patient-reported adverse events, discontinuations, and adherence markers.
A total of 367 eligible patients were identified who had initiated treatment during the study period. Genotype 1 was the most common genotype, and an overall SVR rate of 86.9% was observed. Results were similar to those seen in phase III clinical trials. In addition, adverse events of these medications were more tolerable, and discontinuation rates were lower than with previous therapies.
The aim of this study was to determine current delirium practices in the intensive care unit (ICU) setting and evaluate awareness and adoption of the 2013 Pain, Agitation, and Delirium (PAD) guidelines with emphasis on delirium management.
A large-scale, multidisciplinary, online survey was administered to physician, pharmacist, nurse, and mid-level practitioner members of the Society of Critical Care Medicine (SCCM) between September 2014 and October 2014. A total of 635 respondents completed the survey.
Nonpharmacologic interventions such as early mobilization were used in most ICUs (83%) for prevention of delirium. A majority of respondents (97%) reported using pharmacologic agents to treat hyperactive delirium. Ninety percent of the respondents answered that they were aware of the 2013 PAD guidelines, and 75% of respondents felt that their delirium practices have been changed as a result of the new guidelines. In addition, logistic regression analysis of this study showed that respondents who use delirium screening tools were twice more likely to be fully aware of key components of the updated guidelines (odds ratio [OR] = 2.07, 95% confidence interval [CI] = 1.20-3.60).
Most critical care practitioners are fully aware and knowledgeable of key recommendations in the new guidelines and have changed their delirium practices accordingly.
Summarize available information regarding clinical impact of citalopram on the QTc interval.
A literature search was conducted in Pubmed, EMBASE, and Cochrane databases using the MeSH term "long QT syndrome" and key word "citalopram" on July 11, 2014.
Thirty-one studies were evaluated with 4 included in this review. Studies were excluded if they reported acute overdoses of citalopram or did not report on patient-specific risk factors for long QT syndrome (eg, hypokalemia, bradycardia, and increased age). The majority of the available data is derived from case reports. A number of confounders complicate the determination of a causal link between QTc prolongation and citalopram. Of the 4 studies included for review, none identified significant QTc prolongation in patients taking citalopram 20 to 60 mg daily without the patients having one or more patient-specific risk factors for prolonged QTc.
There is insufficient evidence to establish a causal link between citalopram 20 to 60 mg orally daily and increased risk of TdP. Further research is required to determine the clinical impact and association between citalopram 20 to 60 mg daily and QTc prolongation.
To evaluate the net clinical benefit of tranexamic acid use in patients undergoing total knee or total hip replacement.
This is a retrospective study of patients undergoing total knee or total hip replacement. The primary outcome was the net clinical benefit of tranexamic acid use. Secondary outcomes included length of stay, incidence of venous thromboembolism, change in hemoglobin, and number of units of blood transfused.
Four hundred and six patients were screened for inclusion and 327 patients met inclusion criteria; 174 patients received tranexamic acid versus 153 patients who received usual care. Tranexamic acid demonstrated a positive net clinical benefit versus usual care (40.8% vs 13.7%, P < .01) but did not affect length of stay (3.39 vs 3.37 days, respectively, P = .76). Venous thromboembolism was comparable between groups (2.3% vs 0.7%, P = .38). Average change in hemoglobin and need for transfusion were lower in the treatment group versus the usual care group, respectively (3.46 vs 4.26 mg/dL, P < .01).
Tranexamic acid demonstrated a significant benefit in decreasing change in hemoglobin as well as the need for blood transfusion with no increase in the risk of venous thromboembolism in patients undergoing total knee or total hip replacement.
To compare survey responses between licensed pharmacists who work with or employ new graduates and graduating senior pharmacy students at a college of pharmacy.
This was a retrospective analysis of surveys given to 2 groups of pharmacists and students. Responses to items regarding importance of desirable qualities in new pharmacists and level of preparation of new graduates were analyzed. Qualities included drug information, pharmacology, therapeutics, communication with patients/customers or health care professionals, professionalism, ethics, management, and conflict resolution.
There was consensus between pharmacists and students regarding the importance of all items (P > .05 for all comparisons). However, the percentage of pharmacists versus students who agreed that new graduates communicate effectively differed (86.7% vs 100%, respectively, P < .05). Of pharmacists surveyed at a career fair, 64.1% chose communication as the 1 skill that would distinguish an applicant, and retail and hospital pharmacists displayed a statistically significant (P < .05) difference in the audience (patients/customers vs other health care professionals).
Pharmacists and students agree on the knowledge and skills essential for pharmacy practice but disagree on the level of preparation for effective communication. These results support ongoing efforts to improve the development of communication skills in the professional pharmacy curriculum.
Potentially inappropriate medications (PIMs) have been associated with poor outcomes in older adults. Electronic health record (EHR)-based interventions may be an effective way to reduce PIM prescribing. The main objective of this study was to evaluate changes in PIM prescribing to older adult veterans ≥65 years old in the ambulatory care setting preimplementation and postimplementation of medication alert messages at the point of computerized provider order entry (CPOE). Additional exploratory objectives included evaluating provider type and patient–provider relationship as a factor for change in PIM prescribing. A total of 1539 patients prealert and 1490 patients postalert were prescribed 1952 and 1897 PIMs, respectively. End points were reported as the proportion of new PIM orders of total new prescriptions. There was no significant difference in the rate of new PIMs prealert and postalert overall, 12.6% to 12.0% (P = .13). However, there was a significant reduction in the rate of the top 10 most common newly prescribed PIMs, 9.0% to 8.3% (P = .016), and resident providers prescribed fewer PIMs during both time periods. A simple, age-specific medication alert message during CPOE decreased the incidence of the most frequently prescribed PIMs in older adults receiving care in an ambulatory care setting.
In 2012, pharmacists were integrated into a medical group to provide direct patient care, drug information activities, and health care provider education. The medical group encompasses 40 primary care and 60 specialty offices in Virginia.
To describe the development and implementation of clinical pharmacist services integrated within a medical group.
Pharmacists’ roles and responsibilities, type and number of patient encounters, and identification of strategies to facilitate implementation are described.
From June 2012 to December 2014, pharmacists had 809 patient encounters, which included patient-centered education, medication consults, Medicare annual wellness visits, senior care visits, and comprehensive medication reviews. Pharmacists addressed 403 drug information requests from nurse navigators, providers, and administrators. Pharmacists also have roles in risk management, quality improvement initiatives, and operations that benefit the medical group. Strategies to facilitate implementation include working with organizational leadership, identifying a physician champion, and establishing credibility by being responsive to practice needs and responding to requests in a timely manner to build trust within the health care team.
Integration of pharmacists within health care teams involves more than direct patient care activities. Pharmacists should be involved at the organizational level to have a broader impact on patient and practice levels.
The 2013 Cholesterol Guidelines include a new atherosclerotic cardiovascular disease (ASCVD) risk calculator that determines the 10-year risk of coronary heart disease and/or stroke. The applicability of this calculator and its predecessor, the Framingham risk score (FRS) in Adult Treatment Panel (ATP) III, has been limited in patients with HIV. The objective of this study was to compare the risk scores of ASCVD and FRS in the initiation of statin therapy in patients with HIV.
We conducted a retrospective chart review of patients with HIV on statin therapy from October 1, 2013, to April 1, 2014. Data collection included patient demographics, pertinent laboratory test results, and medication list. The primary end point evaluated the level of agreement between the guidelines.
Of 155 patients who met the inclusion criteria, 116 were treated similarly with both guidelines. This showed a moderate level of agreement (P < .001). Forty-eight of 86 patients requiring statins were placed on the correct intensity statin using the 2013 guidelines. Regardless of which guideline, a majority of patients required statin therapy.
A moderate agreement was found between both guidelines in terms of statin use when applied to an HIV patient population. Based on the 2013 guidelines and taking into account drug interactions with antiretrovirals, 44.2% of the patients were treated with an incorrect statin intensity.
To report perceptions of PharmD candidates regarding a behind-the-counter (BTC) class of medications and to identify perceived barriers to its successful implementation.
PharmD candidates in their second, third, and fourth professional years were invited to complete an online survey. Responses were used to assess perceptions of competency and willingness to participate in a BTC program and perceived preparedness of the current community pharmacy practice environment for a BTC class of medications with regard to 8 specific classes of medications.
The survey response rate was 28%. In all, 78% of respondents agreed or strongly agreed that a BTC class of medications is a change that they would be willing to embrace, and 54% agreed or strongly agreed that their PharmD curriculum provided them with adequate training in laboratory and diagnostic test interpretation. Less than half of the respondents agreed or strongly agreed that community pharmacies are currently equipped with the resources necessary to clinically assess a patient and dispense BTC medications.
PharmD candidates are prepared and willing to participate in a BTC program but believe that the current community practice environment lacks access to resources necessary to do so.
Ensuring a culture that prioritizes and implements patient safety requires educating all future health care professionals to prepare them for their active role in reducing medical errors. There is limited literature describing integration of patient safety education into the curriculum of health care professionals, including pharmacists. The purpose of this study was to evaluate the perceived benefit of integrating patient safety education into a pharmacy curriculum.
Second-year pharmacy students (P2s) completed a patient safety self-study, followed by in-class and experiential application of a root cause analysis (RCA). An electronic, anonymous postsurvey was administered to P2s and third-year pharmacy students (P3s) who had not had formal patient safety education.
Of the 310 students, 53% responded to the survey. Significantly more P2s reported more confidence to describe patient safety and its purpose (P = .0092), describe factors that influence patient safety (P = .0055), and conduct an RCA (P < .001). P2s also reported significantly better ability to conduct a RCA compared to P3s (88.9% positive vs 58.7%, respectively; P ≤ .001).
Both classes perceived patient safety education to be valuable; however, formal education resulted in some significant improvements in perceived confidence and understanding, including ability to conduct an RCA.
Apixaban, an oral factor Xa inhibitor, has no commercially available assay to measure its activity and no specific antidote. To date, recommendations for managing bleeding associated with apixaban are based on studies with animal models and healthy volunteers (who do not have identified thrombogenic risk factors) and expert opinion. No clinical experience has been published in the literature. Ideally, apixaban would be reversed sufficiently to stop a perilous bleed without producing more thrombogenic risk than the patients’ underlying risk factors. Three-factor prothrombin complex concentrate (PCC3) is the least thrombogenic among the suggested reversal agents. Fresh frozen plasma (FFP) is sometimes recommended to add to PCC3, but it adds considerable volume. We describe successful management of an active left gluteal arterial extravasation due to trauma and associated apixaban, in a patient with aortic stenosis and atrial fibrillation, by administration of PCC3 alone, without the added volume of FFP.
Multidrug resistant (MDR) bacterial infections are a major concern of health care providers due to their increasing incidence and associated mortality. In some cases, few or no antibiotics have preserved activity. Beta-lactam administration via continuous infusion can optimize time over minimum inhibitory concentration (MIC). In some cases, use of high-dose continuous infusion (HDCI) may be necessary to achieve serum levels in excess of nonsusceptible MIC values. The use of HDCI beta-lactams is not without risk, specifically neurotoxic adverse effects, which appear dose related. We describe a 64-year-old male who experienced myoclonus and nonconvulsive status epilepticus while receiving HDCI ceftazidime for treatment of multidrug resistant Pseudomonas aeruginosa bacteremia. This report serves as a cautionary example of the potential toxicities associated with HDCI beta-lactams and supports the importance of risk–benefit analysis prior to and during treatment. Additionally, the use of serum drug level monitoring may be necessary to better prevent or predict toxicity.
Coagulopathy resulting from chronic liver disease (CLD) creates uncertainty regarding the risks and efficacy of pharmacologic venous thromboembolism (VTE) prophylaxis (ppx). We aim to describe patient characteristics associated with VTE ppx and the clinical impact of ppx in hospitalized patients with CLD.
This retrospective study included patients with CLD, an international normalized ratio (INR) of ≥1.3, and hospital stay of ≥72 hours. Baseline characteristics, incidence of VTE, and major bleeding were compared between patients given ppx and those not given ppx.
Of 300 patients with CLD included, 157 (52%) received VTE ppx. Characteristics associated with VTE ppx were lower activated partial thromboplastin time, INR, bilirubin, and Model for End-Stage Liver Disease (MELD) score as well as a higher Padua Prediction Score, hemoglobin, platelet count, and antiplatelet use. VTE occurred in 12 (7.6%) ppx versus 4 (2.8%) non-ppx patients (P = .07). Major bleeding occurred in 47 (30%) ppx versus 49 (34.3%) non-ppx patients (P = .46). Ppx was not associated with VTE or bleeding outcomes by multivariate regression.
The use of VTE ppx in hospitalized patients with CLD was not associated with a lower risk of VTE nor did it increase the risk of bleeding. Further studies examining the risks and benefits of VTE ppx in this population are needed.
The objective of this study was to explore patient perceptions and the practical implication of using a brief 9-item scale to screen for medication-related problems in community pharmacies.
Semistructured, audio-recorded, telephonic interviews were conducted with 40 patients who completed the scale and reviewed its results with their pharmacist. Audio recordings were transcribed verbatim and analyzed using qualitative methods to identify themes.
Patients generally reported the scale was simple to complete and could be used easily in other community pharmacies. Participants shared they had increased understanding of their medications and confidence that their medication therapy was appropriate. Several patients reported having actual medication-related problems identified and resolved through the use of the scale. Patients also reported improved relationships with pharmacists and heightened belief in the value provided by pharmacists.
This screening tool may have value in increasing patients’ understanding of and confidence in their medications, enhancing pharmacist–patient relationships, and identifying problems requiring additional interventions.
The increasing number of newer type 2 diabetes therapies has allowed providers an increased armamentarium for the optimal management of patients with diabetes. In fact, these newer agents have unique benefits in the management of type 2 diabetes. However, they are also associated with certain adverse effects. This review article aims to describe the notable adverse effects of these newer antidiabetic therapies including the glucagon-like peptide 1 receptor agonists, dipeptidyl peptidase-4 inhibitors, and the sodium-glucose cotransporter 2 inhibitors. The adverse effects reviewed herein include pancreatitis, medullary thyroid carcinoma, heart failure, gastrointestinal disturbances, renal impairment, and genitourinary infections. More clinical data are necessary to solidify the association of some of these adverse effects with the newer diabetes agents. However, it is important for health care practitioners to be well informed and prepared to properly monitor patients for these adverse effects.
This article provides an overview of the current use of point-of-care testing (POCT) and its utility for patients’ self-management of chronic disease states. Pharmacists utilize POCT to provide rapid laboratory diagnostic results as a monitoring tool in the management of their patients and in order to improve medication outcomes. Considerations for the transition to use of POCT in the home to further improve disease management and improve health care cost-effectiveness are discussed. Devices available for home use include those suitable for management of diabetes mellitus, hypertension, congestive heart failure, and anticoagulation. Many of these devices include software capabilities enabling patients to share important health information with health care providers using a computer. Limitations and challenges surrounding implementation of home POCT for patients include reliability of instrumentation, ability to coordinate data collection, necessary training requirements, and cost-effectiveness. Looking forward, the successful integration of POCT into the homes of patients is contingent on a concerted effort made by all members of the health care team.
To evaluate the impact of a student pharmacist-run targeted medication intervention (TMI) program.
Student pharmacists in their third professional year resolved TMIs at 5 independent pharmacies under the supervision of a pharmacist. A claims report of completed TMIs from the medication therapy management (MTM) platform, which captured the category and outcome of the TMIs and the estimated cost avoidance (ECA) level, was analyzed using descriptive statistics. Time spent was calculated using an estimation based on each of the tasks required to complete the TMI.
Of the 156 TMIs that were billed, 42 (26.9%) were accepted, 24 (15.4%) were rejected, and 90 (57.7%) were unable to be reached. For TMIs where the prescribers or patients were reached, the acceptance rates were 20% and 71%, respectively. Student pharmacists spent a total of 25.2 hours completing TMIs, and the pharmacist spent 2 hours on administrative tasks. Total revenue generated from all TMIs was US$1058, which led to a revenue generation of US$38.90/h. Successfully completing 42 TMIs resulted in a savings to the health care system of approximately US$121 000.
This pilot study demonstrates an innovative model for community pharmacies to complete TMIs by utilizing student pharmacists under the supervision of a pharmacist.
The uptake of generic immunosuppressants lags comparatively to other drug classes, despite that the Food and Drug Administration (FDA) uses identical bioequivalence standards for all drugs. Transplant societies acknowledge the cost savings associated with generic immunosuppressants and support their use following heart, lung, kidney, or bone marrow transplantation. Seven studies of the pharmacokinetics or clinical efficacy of generic mycophenolate mofetil compared to the innovator product are published; all studies and products were ex-United States. Three studies did not demonstrate any pharmacokinetic differences between generic and innovator products in healthy subjects, achieving FDA bioequivalence requirements. Two studies in renal allograft recipients demonstrated no difference in area under the curves between generic and innovator products, and in one, the maximum concentration (Cmax) fell outside the FDA regulatory range. Two studies revealed no difference in acute organ rejection or graft function in renal allograft recipients. Patient surveys indicate that cost is a barrier to immunosuppressant adherence. Generics present a viable method to reduce costs to payers, patients, and health care systems. Adherence to immunosuppressants is crucial to prevent graft failure. An affordable regimen potentially confers greater adherence. Concerns regarding the presumed inferiority of generic immunosuppressants should be assuaged by regulatory requirements for bioequivalency testing, transplant society position statements, and pharmacokinetic and clinical studies.
Cefepime and meropenem are used frequently in hospitalized patients for broad-spectrum empiric coverage, however, practitioners are often reluctant to prescribe these antibiotics for patients with a self-reported nonsevere, nontype I allergic reaction to penicillin.
Retrospective review of electronic medical records of adults with a self-reported allergy to penicillin who received at least 1 dose of cefepime, ceftriaxone, cefoxitin, cephalexin, or meropenem to assess incidence and type of allergic reactions.
Of 175 patients included, 10 (6%) patients experienced an allergic reaction. The incidence for individual study drugs were cefepime 6% (6 of 96), meropenem 5% (3 of 56), cefoxitin 8% (1 of 13), ceftriaxone 0% (0 of 69), and cephalexin 0% (0 of 8). The majority of patients experienced a rash with or without pruritus and fever. Patients with a concomitant "sulfa" allergy (odds ratio [OR] 5.4, 95% confidence interval [CI] 1.4-21, P = .02) or ≥3 other drug allergies (OR 6.4, 95% CI 1.3-32, P = .025) were more likely to have an allergic reaction.
In one of the largest retrospective reviews of hospitalized patients who received full dose therapy with cefepime, ceftriaxone, and meropenem, the incidence of allergic reactions was low and reactions were mild. Cefepime, ceftriaxone, and meropenem can be considered for use in patients with a self-reported nontype I penicillin allergy.
This cross-sectional study enrolled 180 patients at a private family practice in Virginia. Total serum vitamin D concentrations were obtained weekly from January 30, 2013, through March 30, 2013, in consecutive patients regularly scheduled for laboratory work at the practice. Patients were categorized into 2 groups and analyzed for variant alleles in vitamin D receptor (VDR; rs2228570), cytochrome P450 2R1 (CYP2R1; rs10741657), 7-dehydrocholesterol reductase (DHCR7; rs12785878), and group-specific component (GC; rs2282679) to determine whether variants of those alleles influenced total serum 25(OH)D concentrations. One-hundred and eighty patients were enrolled, with 40 (22%) being sufficient, 25-hydroxy vitamin D level 25(OH)D ≥ 30 ng/mL, and 140 (78%) being insufficient, 25(OH)D < 30 ng/mL. Of the 4 genes, 2 genes, CYP2R1 (rs10741657) and GC (rs2282679), demonstrated a significant association related to vitamin D status. Subjects with 1 or more variant alleles at rs10741657 were almost 3.7 (odds ratio [OR] 3.67; 95% confidence interval [CI]: 1.35-9.99) times more likely be insufficient in vitamin D and subjects with 1 or more variant alleles at rs2282679 were about half (OR 0.42; 95% CI: 0.18-0.93) as likely to be insufficient in vitamin D. Allelic variations in CYP2R1 (rs10741657) and GC (rs2282679) affect vitamin D levels, but variant alleles on VDR (rs2228570) and DHCR7 (rs12785878) were not correlated with vitamin D deficiency, 25(OH)D < 30 ng/mL.
To assess the feasibility of engaging second professional year student pharmacists in the medication reconciliation process on hospital and health system pharmacy practice outcomes.
Student pharmacists in their second professional year in the Doctor of Pharmacy degree program at our institution were randomly selected from volunteers to participate. Each participant completed training prior to completing three 5-hour evening shifts. Organizational metrics, student pharmacist perception regarding quality of interactions with health care professionals, and pharmacist perceptions were collected.
A total of 83 medication histories were performed on complex medical patients (57.0 ± 19.2 years, 51% female, 65% Caucasian, 12 ± 6 medications); of those, 93% were completed within 24 hours of hospital admission. Second professional student pharmacists completed on average 1.9 ± 0.6 medication histories per shift (range 1-3). Student pharmacists identified 0.9 medication-related problems per patient in collaboration with a pharmacist preceptor. Student pharmacists believed the quality of their interactions with health care professionals in the Student Medication and Reconciliation Team (SMART) program was good or excellent. The program has been well received by clinical pharmacists involved in its design and implementation.
This study provides evidence that second professional year student pharmacists can assist pharmacy departments in the care of medically complex patients upon hospital admission.
Purpose: The primary objective of this study was to determine the change in the adherence questionnaire score from the initial pharmacist intervention to 60 to 90 days follow-up. The secondary objective of this study was to investigate the impact of the type of pharmacist intervention on questionnaire scores. Methods: Administration of an adherence questionnaire to guide interventions has become the standard of care for patients during appointments with clinical pharmacy specialists at 3 primary care clinics. Subjects who received a questionnaire between November 4, 2013, and January 15, 2014, were included. These subjects received a second questionnaire 60 to 90 days after the first questionnaire to identify changes resulting from the pharmacist’s interventions. A scoring system was utilized to quantify patients’ responses to both the preintervention and postintervention questionnaires. The type of intervention completed was determined at each pharmacist’s clinical discretion. Results: Adherence scores increased significantly 60 to 90 days after administration of the questionnaire with a pharmacist’s intervention. Medication reminders, simplifying medication regimens, discount program referrals, disease-state information, medication information, and therapeutic interchanges, all increased adherence scores. Conclusion: A standardized tool to assess and address adherence was effectively utilized by 9 pharmacists at 3 clinics. The use of a standardized tool to guide adherence interventions is an effective way to increase adherence to medication therapy.
Antimicrobial resistance is a national public health concern. Misuse of antimicrobials for conditions such as upper respiratory infection, urinary tract infections, and cellulitis has led to increased resistance to antimicrobials commonly utilized to treat those infections, such as sulfamethoxazole/trimethoprim and flouroquinolones. The emergency department (ED) is a site where these infections are commonly encountered both in ambulatory patients and in patients requiring admission to a hospital. The ED is uniquely positioned to affect the antimicrobial use and resistance patterns in both ambulatory settings and inpatient settings. However, implementing antimicrobial stewardship programs in the ED is fraught with challenges including diagnostic uncertainty, distractions secondary to patient or clinician turnover, and concerns with patient satisfaction to name just a few. However, this review article highlights successful interventions that have stemmed inappropriate antimicrobial use in the ED setting and warrant further study. This article also proposes other, yet to be validated proposals. Finally, this article serves as a call to action for pharmacists working in antimicrobial stewardship programs and in emergency medicine settings. There needs to be further research on the implementation of these and other interventions to reduce inappropriate antimicrobial use to prevent patient harm and curb the development of antimicrobial resistance.
Delirium, described as an acute neuropsychiatric syndrome, occurs commonly in critically ill patients and leads to many negative outcomes including increased mortality and long-term cognitive deficits. Despite the lack of clinical data supporting the use of antipsychotics for the management of intensive care unit (ICU) delirium, pharmacological interventions are often needed to control acutely agitated patients. Given that the most current guidelines do not advocate the use of haloperidol for either the prevention or treatment of ICU delirium due to a lack of evidence, second-generation antipsychotics (SGAs) have been commonly used as alternatives to haloperidol for ICU patients with delirium. Nonetheless, the evidence supporting the use of SGAs to treat ICU delirium remains limited. This review is designed to assess the available clinical evidence and highlights the different neuropharmacological and safety properties of SGAs in order to guide the rational use of SGAs for the treatment of ICU delirium.
(1) To identify physicians’ preferences in regard to pharmacist-provided medication therapy management (MTM) communication in the community pharmacy setting; (2) to identify physicians’ perceived barriers to communicating with a pharmacist regarding MTM; and (3) to determine whether Missouri physicians feel MTM is beneficial for their patients.
A cross-sectional prospective survey study of 2021 family and general practice physicians registered with MO HealthNet, Missouri’s Medicaid program.
The majority (52.8%) of physicians preferred MTM data to be communicated via fax. Most physicians who provided care to patients in long-term care (LTC) facilities (81.0%) preferred to be contacted at their practice location as opposed to the LTC facility. The greatest barriers to communication were lack of time and inefficient communication practices. Improved/enhanced communication was the most common suggestion for improvement in the MTM process. Approximately 67% of respondents reported MTM as beneficial or somewhat beneficial for their patients.
Survey respondents saw value in the MTM services offered by pharmacists. However, pharmacists should use the identified preferences and barriers to improve their currently utilized communication practices in hopes of increasing acceptance of recommendations. Ultimately, this may assist MTM providers in working collaboratively with patients’ physicians.
The prevention of pregnancy remains an important part of the practice of medicine. Contraception can occur at a number of points in the basic reproductive biological process and through a number of contraceptive product options. Pharmacists are health care providers appropriately positioned to assist patients in suitable contraceptive product selection based on their personal situations and lifestyles. This article provides an overview of available products for prevention of pregnancy and associated risks and benefits. Contraceptive products are categorized by their hormonal content and method of action. Hormonal options include oral contraceptive pills, contraceptive patch, implants, injection, intravaginal, and intrauterine devices. Barrier products prevent pregnancy by creating a physical obstacle to the successful fertilization of an egg by sperm. All products and methods are associated with benefits and potential complications that must be considered as patients, and health care providers select the most satisfactory option.
Inhaled medications are recommended as first-line treatment for chronic obstructive pulmonary disease (COPD) and can reduce exacerbations and hospitalizations. Low health literacy is associated with poor inhaler technique.
This study examined whether handouts written specifically for patients with low health literacy are more effective in showing patients how to use their medications when compared to standard education materials.
A prospective, experimental study was performed at a community-based hospital. Patients included in the study were admitted to the hospital with a diagnosis of COPD, taking at least 1 inhaled medication and identified as having low health literacy based on a Rapid Estimate of Adult Literacy in Medicine—Short Form. Low health literacy handouts were compared against the standard hospital educational materials for inhalers. Correct technique during each demonstration was evaluated using a standardized checklist.
Mean baseline scores for inhaler technique were 12.2 ± 2.2 steps correct for the control group and 13.4 ± 1.3 for the low health-literacy group of the 18 maximum points (P = nonsignificant). The mean change in inhaler technique score for the control group was 1.0 ± 1.8, while the mean change in inhaler technique score for the low health-literacy group was 2.1 ± 2.7 (P = .03).
Inflammatory bowel diseases (IBDs) are chronic inflammatory disorders affecting the gastrointestinal (GI) tract that encompass Crohn’s disease (CD) and ulcerative colitis (UC). In these disease states, epithelial damage of the intestinal mucosa is evident due to increased lymphocyte trafficking to the area, which affects the normal intestinal barrier function. Currently available pharmacotherapy can be limited in terms of efficacy and associated toxicities. Newer agents have emerged, including the monoclonal antibody natalizumab, which antagonizes integrin, an important component within the inflammation cascade. Natalizumab works by modulating both the GI and brain biologic responses and as a result there is risk of the opportunistic infection known as progressive multifocal leukoencephalopathy (PML), putting patients at risk for severe disability and death. Vedolizumab, another integrin inhibitor, is selective for modulating the gut biologic response but not the brain, consequently decreasing the risk for PML. To generate information regarding the role of vedolizumab in the treatment of IBD, a literature search was conducted, yielding 7 phase I to III clinical trials. This article serves as a summary of efficacy, safety, and other relevant information from clinical studies to explore the role of vedolizumab in the treatment of CD and UC.
Chronic use of atypical antipsychotics may lead to metabolic abnormalities including hyperglycemia. Although evidence supports acute hyperglycemic episodes associated with atypical antipsychotic use, the acute use of atypical antipsychotics in the intensive care unit (ICU) setting has not been studied. The purpose of this study is to evaluate the occurrence of hyperglycemia in ICU patients receiving newly prescribed atypical antipsychotic.
Of the 273 patient charts reviewed, 50 patients were included in this study. Approximately 45% of patients experienced at least 1 hyperglycemic episode (blood glucose >180 mg/dL) after the initiation of an atypical antipsychotic in the ICU. Of the patients experiencing at least 1 hyperglycemic episode, 60% experienced multiple distinct hyperglycemic episodes. In this study, quetiapine was the most commonly used atypical antipsychotic, 19 (38%) patients were discharged from the ICU on the atypical antipsychotic, 6 (12%) patients died in the ICU, and 31 (62%) patients were treated with an antihyperglycemic agent. Logistic regression analysis showed that women and ICU patients with a higher Acute Physiology and Chronic Health Evaluation II (APACHE II) score were significantly more likely to have multiple hyperglycemic episodes.
Patients admitted to the ICU and initiated on an atypical antipsychotic may develop hyperglycemia independent of other glucose-elevating factors. The direct correlation of these agents to resulting acute hyperglycemia is unknown. Further studies are needed to investigate the link between atypical antipsychotics and acute hyperglycemia and the clinical significance of the impact on patient outcomes.
To characterize requests received through an academic drug information consultation service related to complementary and alternative medicines.
A retrospective review and descriptive analysis of drug information consultations was conducted.
A total of 195 consultations related to complementary and alternative medicine were evaluated. All consultation requests involved questions about dietary supplements. The most common request types were related to safety and tolerability (39%), effectiveness (38%), and therapeutic use (34%). Sixty-eight percent of the requests were from pharmacists. The most frequent consultation requests from pharmacists were questions related to drug interactions (37%), therapeutic use (37%), or stability/compatibility/storage (34%). Nearly 60% of complementary and alternative medicine-related consultation requests were able to be completely addressed using available resources. Among review sources, Natural Medicines Comprehensive Database, Clinical Pharmacology, Micromedex, and Pharmacist’s Letter were the most common resources used to address consultations.
Utilization of a drug information service may be a viable option for health care professionals to help answer a complementary and alternative medicine-related question. Additionally, pharmacists and other health care professionals may consider acquiring resources identified to consistently answering these questions.
To provide education to community pharmacists regarding the registration and use of the Texas prescription drug monitoring program (PDMP) and to assess the impact of the education on pharmacists’ perceptions of the PDMP.
The study design was a descriptive, pre and post, cross-sectional survey conducted among community pharmacists attending a PDMP education program. The program was designed to present the PDMP as a public health tool available to assist pharmacists with dispensing decisions related to controlled prescription drugs.
Of the 24 pharmacists who completed the survey, 23 were already registered to use the PDMP. However, all 23 felt that the program successfully educated users regarding the PDMP and agreed that other community pharmacists would benefit from the program presented. After the program, 14 participants responded they would very likely use the PDMP in the next 30 days. Recognition of the use of PDMPs as a program for both pharmacists and physicians was increased from 12.5% (pre) to 73.9% (post).
Pharmacists found the educational program beneficial and they were very likely to use the PDMP in the future. Perceptions of the Texas PDMP were changed from pre- to post-education program, with recognition that a PDMP can be a beneficial tool for pharmacy practice.
This study assessed longitudinal trends in pharmacy staffing and services in the 6 New England states by comparing survey results from 2008 and 2013.
A validated 32-item survey was mailed in 2008 and 2013 to a random sample of 2000 pharmacists. Each sample represented approximately 15% (2008) and 13% (2013) of the active rosters.
Response rates were 24% in 2008 and 23% in 2013. In all, 45% of 2013 respondents reported a pharmacist position vacancy in the past 12 months versus 62% in 2008. In all, 12% of 2013 respondents agreed or strongly agreed with a statement regarding pharmacists’ shortage versus 77% in 2008. Disease management services were reported to be offered by 23% of 2013 respondents versus 28% in 2008. Reasons for not offering the services in 2013 included the lack of staffing (61%), expertise (28%), and reimbursement (29%). In 2008, these results were 74%, 33%, and 31%, respectively.
The pharmacist shortage within New England was alleviated during 2008 to 2013. Participation of pharmacists in disease management services did not follow staffing trends as fewer pharmacists reported providing services. Key barriers to services provision persist and consideration of how to resolve them (medication therapy management reimbursement and additional education) should be explored.
Urine drug screening has become standard of care in many medical practice settings to assess compliance, detect misuse, and/or to provide basis for medical or legal action. The antibody-based enzymatic immunoassays used for qualitative analysis of urine have significant drawbacks that clinicians are often not aware of. Recent literature suggests that there is a lack of understanding of the shortcomings of these assays by clinicians who are ordering and/or interpreting them. This article addresses the state of each of the individual immunoassays that are most commonly used today in order to help the reader become proficient in the interpretation and application of the results. Some literature already exists regarding sources of "false positives" and "false negatives," but none seem to present the material with the practicing clinician in mind. This review aims to avoid overwhelming the reader with structures and analytical chemistry. The reader will be presented relevant clinical knowledge that will facilitate appropriate interpretation of immunoassays regardless of practice settings. Using this review as a learning tool and a reference, clinicians will be able to interpret the results of commonly used immunoassays in an evidence-based, informed manner and minimize the negative impact that misinterpretation has on patient care.
The study seeks to investigate the impact of Food and Drug Administration’s black box warning (BBW) on the use of atypical antipsychotics (AAP) and nonantipsychotic psychotropic alternatives in noninstitutionalized elderly population diagnosed with dementia.
The Medical Expenditure Panel Survey (2004 through 2007) was utilized as the data source. Medication use in elderly patients (≥65 years) was defined as taking at least 1 medication for dementia. We performed a statistical comparison of prewarning (2004-2005) and postwarning (2006-2007) periods with respect to AAP and nonantipsychotic psychotropic use to examine the impact of labeling changes.
A bivariate analysis did not yield statistically significant change in either the AAP or nonantipsychotic psychotropic use, pre- versus postwarning. However, multivariate logistic-regression analyses revealed greater odds for antidementia (odds ratio [OR] = 1.976, P = .0195) and benzodiazepine (OR = 3.046, P = .0227) medication use in postwarning period compared to the prewarning period.
The regulatory warnings and labeling changes regarding off-label use of AAPs in dementia treatment showed minimal impact on their actual use in noninstitutionalized populations. A corresponding increase in the use of nonantipsychotic psychotropics explains that BBW might have resulted in a compensatory shift in favor of benzodiazepines and antidementia medications. Additional research should be conducted to examine the long-term impact of BBW on antipsychotic prescribing changes.
To evaluate the effectiveness of an integrated Pharmacy Transitions of Care (PTC) pilot program on reducing hospital readmissions and improving patient satisfaction.
This prospective observational cohort study compares patients who participated in the PTC program to a control of usual hospital discharged patients during January through April 2014. The PTC program provided discharge medication review, medication counseling, delivery of medications to bedside, clinic scheduling, and follow-up phone calls. The primary outcome measure was 30-day readmissions. Secondary outcomes included emergency department (ED) visits, pharmacist interventions, and patient satisfaction.
Seventy patients participated in the PTC program. Compared to the control (n = 725), the study group had decreased 30-day all-cause readmissions (5.7% vs 13.8%, P = .08), 30-day readmissions for the same diagnosis (2.9% vs 8.1%, P = .18), and ED visits (18.6% vs 25%, P = .82). Twenty-five interventions during discharge medication review included discontinuation of unnecessary medications and correction of medication dose or frequency. The majority of patients were satisfied with the medication education provided (94%) and the timely delivery of prescriptions to bedside (96%).
There was no significant difference in 30-day readmission rates. However, pharmacists were able to make a positive impact on patient satisfaction and improve understanding of medications during discharge.
There is no standardization for teaching activities or a requirement for residency programs to offer specific teaching programs to pharmacy residents. This study will determine the perceived value of providing teaching opportunities to postgraduate year 1 (PGY-1) pharmacy residents in the perspective of the residency program director. The study will also identify the features, depth, and breadth of the teaching experiences afforded to PGY-1 pharmacy residents.
A 20-question survey was distributed electronically to 868 American Society of Health-System Pharmacists-accredited PGY-1 residency program directors.
The survey was completed by 322 program directors. Developing pharmacy educators was found to be highly valued by 57% of the program directors. Advertisement of teaching opportunities was found to be statistically significant when comparing program directors with a high perceived value for providing teaching opportunities to program demographics. Statistically significant differences were identified associating development of a teaching portfolio, evaluation of Advanced Pharmacy Practice Experiences students, and delivery of didactic lectures with program directors who highly value developing pharmacy educators.
Future residency candidates interested in teaching or a career in academia may utilize these findings to identify programs that are more likely to value developing pharmacy educators. The implementation of a standardized teaching experience among all programs may be difficult.
To assess patient satisfaction, perception of self-management, and perception of disease state knowledge with pharmacist-led diabetes and cardiovascular disease state management (DSM) programs.
A self-insured chain of grocery store pharmacies in the Kansas City metropolitan area administers pharmacist-led diabetes and cardiovascular DSM programs for eligible employees and dependents. A modified version of the Diabetes Disease State Management Questionnaire was used to assess patient satisfaction with the DSM programs. Demographic information was also collected. Survey items were based on a 5-point Likert scale (1 = strongly disagree and 5 = strongly agree). Patients were eligible to complete the survey if he or she had been in at least 1 DSM program for 6 months. Data were assessed using descriptive statistics and analysis of variance.
Across 20 pharmacies, 281 eligible participants were identified, and 46% (n = 128) completed a survey. Means for summed items relating to overall satisfaction (8 items), self-management (5 items), and knowledge (4 items) were 36.6/40 (standard deviation [SD] = 3.9), 20.9/25 (SD = 3.4), and 17.6/20 (SD = 2.1), respectively. Participant comments further indicated that the program and pharmacists are helpful and increase motivation and accountability.
Positive patient responses to the program support use of pharmacist-led DSM programs.
The use of dornase alfa in a non-cystic fibrosis population has been proposed to help improve atelectasis and secretions. Data evaluating dornase alfa in a non-cystic fibrosis population are limited, and the prescribing practices at a tertiary academic medical center are unknown.
Adult patients ≥18 years of age were included if they received inhaled dornase alfa. Patients were excluded if they had cystic fibrosis. Data collected included demographic data, dornase alfa prescribing patterns, concomitant inhaled therapy, blood gas data, and documented efficacy and safety data.
Seventy-six orders for dornase alfa therapy were included in the analysis. Of the patients, 18% had asthma and 19% had chronic obstructive pulmonary disease. Seventy-seven percent of the patients received concomitant inhaled therapy. Eighty-three percent of orders were for 2.5 mg of dornase alfa twice daily. The median (interquartile range [IQR]) number of doses received per patient was 6 (4-13) with a median (IQR) duration of 3 (2-7) days. After inhaled dornase alfa administration, 11% of patients were able to cough productively. No safety issues related to inhaled dornase alfa therapy were noted.
Inhaled dornase alfa is commonly prescribed to improve atelectasis and secretions in a non-cystic fibrosis patient population at a tertiary academic medical center.
The emergence of resistant Escherichia coli to fluoroquinolones (FQs) is of growing concern, yet the latest guidelines for the treatment of pyelonephritis still recommend FQs as first-line treatment. Our primary objective was to determine the impact of discordant prescribing of FQs in E coli pyelonephritis on hospital length of stay (LOS) and early clinical response (ECR).
We retrospectively compared discordant and concordant prescribing of FQs for LOS and ECR. We also compared FQs, ceftriaxone, piperacillin/tazobactam, and carbapenems for these clinical outcomes.
Forty-nine patients included in the comparison between discordant (n = 9) and concordant (n = 40) prescribing of FQs. There was significantly lower ECR in patients with discordant prescribing of FQs (38 of 40, 95% vs 5 of 9, 55.6%, P = .0074) and a trend toward longer LOS (4 [2.3] days vs 3 [2.0] days, P = .0571). Illness severity, estimated using Simplified Acute Physiology Score (SAPS II) score, was similar between groups (P = .717).
There was a significantly decreased ECR and a trend toward increased LOS when FQs were used in FQ-resistant E coli. Regarding alternative treatment for E coli pyelonephritis, ceftriaxone was as effective as concordant FQs and significantly better than discordant FQs.
This study aims to assess the impact of postoperative intravenous (IV) acetaminophen on opioid requirements and pain scores in patients following gynecologic procedures.
A retrospective cohort study of patients undergoing gynecologic procedures was conducted to assess the impact of adding scheduled IV acetaminophen to postoperative analgesic regimens. The control group consisted of patients admitted prior to formulary addition of IV acetaminophen; the study group consisted of patients admitted after formulary addition of IV acetaminophen who received scheduled IV acetaminophen for at least the first 24 hours postoperatively. Opioid requirements 0 to 24 hours postoperatively served as the primary end point. Secondary end points included average pain score, cumulative acetaminophen dose, nonopioid analgesic requirements, and rate of adverse events 0 to 24 hours postoperatively.
One hundred and thirty-seven patients who underwent a gynecologic procedure from January 2009 to April 2013 were included in this study. Baseline characteristics were similar between the groups. In the first 24 hours postoperatively, there was no difference in opioid requirements between the groups (21 mg [interquartile range, IQR, 15-39.8 mg] vs 32.6 mg [IQR, 16.75-41 mg], P = 0.150). The average pain score and incidence of adverse events did not differ between the 2 groups.
Postoperative administration of IV acetaminophen did not provide a significant opioid-sparing effect in patients undergoing gynecologic procedures.
Although access to emergency contraception (EC) has increased with nonprescription status and approval of Plan B One-Step without age restrictions, barriers may still remain in patient education. This study assesses product availability and accuracy of information for EC among community pharmacies in Rhode Island, comparing changes from 2009 to 2012.
Two female investigators posing as patients seeking EC followed a standardized script over telephone conversations. Investigators assessed EC availability, product use information, and cost at all community (retail) pharmacies in Rhode Island. Data were reported as group results with no identifiers. Chi-square and Fisher exact tests were used to analyze results.
During spring of 2009 and 2012, 165 and 171 pharmacies were telephoned, respectively. Approximately 90% of pharmacies stocked EC both years. In all, 62% versus 28% (P < .001) indicated EC should be taken as soon as possible; 82.5% versus 87.7% (P = .220) provided correct administration information; 67% versus 84% (P < .001) warned about adverse effects; and 67% versus 53% (P = .123) provided the correct minimum age for purchase.
Access to nonprescription EC in Rhode Island is very good. Sites not stocking EC should reassess plans for patients to obtain medication. There is need for reeducation on EC labeling to improve counseling provided over the telephone.
The American Society of Health-System Pharmacists (ASHP) requires that accredited residency programs provide pharmacy residents the opportunity to perform a practice-based project. The objective of this study was to evaluate the impact of pharmacy residency research training on residents’ actual versus perceived ability to solve practice-related problems in their professional careers.
This cross-sectional study surveyed postgraduate year 1 (PGY1) pharmacy practice residents who completed training at a large academic medical center between 2007 and 2013. The survey consisted of 3 areas of assessment, that is, (1) general demographics, (2) perceived research abilities, and (3) self-reported research productivity.
A total of 39 residents were eligible; of those, 27 completed the survey (69.2% response rate). Participants reported low perceived ability for conductance of some research activities including study design development, implementation, and publication. No association between perceived research ability and self-reported research productivity was found. Research experience prior to residency training strongly predicted for subsequent publication after completion of PGY1 residency training (P < .0001).
New training mechanisms may be needed to optimize research training that will provide residents with greater emphasis on areas of perceived deficiency.
To evaluate the effect transition of care follow-up and counseling performed by a pharmacist, within a physician’s practice, can have on 30-day hospital readmissions among Medicare patients when compared to the current standard of care.
A pharmacist telephonically contacted patients ≥65 years with Medicare insurance following hospital discharge to perform medication reconciliation, review discharge instructions, and schedule a follow-up appointment (n = 34). At this follow-up appointment, the pharmacist reviewed the patient’s electronic medical record (EMR) and communicated recommendations to the physician. The current standard of care, which does not involve a pharmacist, at a similar local physician practice was used as a comparative group (n = 45).
The difference in 30-day readmission rates did not reach statistical significance (P = .27); however, there was a trending decrease in the percentage of patients readmitted between the control and the intervention groups (26.7% vs 14.7%). Additionally, there was nearly a statistically significant decrease in readmission rates for those patients who interacted with the pharmacist face to face versus only telephonically (P = .05).
These results impact the decision to continue and expand the pilot program and demonstrate that pharmacists in the ambulatory setting based within a patient-centered medical home have a potential role in decreasing 30-day hospital readmissions.
Anticoagulation therapy is often indicated for the treatment and prevention of venous thromboembolism (VTE). Despite advances in anticoagulant management with parenteral anticoagulants and vitamin K antagonists, limitations to their use still exists, leading to investigation of alternative anticoagulants such as factor Xa inhibitors and direct thrombin inhibitors. To date, 3 target-specific oral anticoagulants (TSOACs) are Food and Drug Administration approved; several other agents are currently in development to optimize VTE management and minimize bleeding risks. The objective of this systematic review article is to provide clinicians an overview of the clinical evidence on the investigational TSOACs for the treatment and prevention of VTE. Of the agents in development, edoxaban holds the most promise due to robust data supporting its clinical benefit with a similar bleeding risk to currently approved agents. Clinicians should understand the TSOACs under investigation, since differences in pharmacokinetics and pharmacodynamics may influence clinical decision making and agent selection for management of VTE. Currently, no direct comparisons between TSOACs have been conducted. Agents under investigation have yet to overcome the major limitations of the currently existing TSOACs. Further studies are necessary to clarify which TSOAC agent is best for management of VTE in clinical practice.
A 30-year-old male patient developed a hallucinogen persisting perception disorder (HPPD) after smoking cannabis laced with phencyclidine (PCP) or lysergic acid diethylamide (LSD) 10 years prior to hospital admission. Clinically, he reported seeing vivid, saturated colors and caricature-like objects. The patient described perceiving objects or people in motion as moving faster than normal. He reported living in a dream-like state and feeling numb and detached from other people and his surroundings. Upon pharmacotherapy initiation, facility transfer, and subsequent discharge from an acute psychiatry unit, he ultimately committed suicide. Although hallucinogen abuse is common in the United States, this case suggests that HPPD maybe significantly underdiagnosed and undertreated. In some cases, this oversight may perpetuate years of unnecessary patient suffering and can ultimately lead to severe depression and suicide.
For a patient who is deaf, providing patient care can be more difficult due to communication barriers. This study was conducted in order to better understand pharmacists’ current means of communicating with deaf patients as well as investigating pharmacists’ knowledge of their legal responsibility to these patients.
Surveys were used to gather information from pharmacists and were distributed in areas with a large population of deaf patients.
Of the 73 pharmacists who completed surveys, 50 (68.5%) of them interact with at least 1 to 5 deaf patients monthly. Pharmacists responded that accessibility of interpreters is the most significant barrier to communication and providing written material is the method most used to communicate with deaf patients. None of the 73 pharmacists who completed the survey felt that they have a legal obligation to provide and pay for an interpreter.
When interacting with a deaf patient, pharmacists may experience communication barriers. Pharmacists should strive to appropriately communicate with the deaf as well as familiarize themselves with legal obligations to this patient population.
Few studies have investigated the timing of vancomycin trough concentration collection in the inpatient setting. To date, there are no published studies on the impact of targeted nursing staff education on the appropriate timing of vancomycin trough concentration collection.
To evaluate the impact of educational sessions on nursing staff knowledge regarding vancomycin and proper collection of troughs.
The nursing staffs of 5 hospital units with a high volume of vancomycin usage were targeted for voluntary vancomycin educational sessions. Comprehension of the educational content was measured by a 5-question pre-/posteducation quiz. Vancomycin trough concentrations were evaluated during a 2-month period pre-/posteducation for appropriate timing of sample draw, defined as ≤45 minutes prior to the next scheduled vancomycin dose.
A total of 114 nurses participated in the education sessions. The mean pretest score was 3.91 and the mean posttest score was 4.89 (P < .001). Preeducation, 69% of trough concentrations were collected appropriately. Posteducation, 74% of samples were collected within the 45-minute time frame (P = .20).
A significant increase in short-term comprehension regarding vancomycin was seen posteducation. There was a nonsignificant increase in appropriately timed trough concentration collection posteducation. Further education of nursing staffs may be necessary to lessen timing errors.
This study aims to develop a systematic search strategy and test its validity and reliability in terms of identifying projects published in peer-reviewed journals as reported by residency graduates through an online survey.
This study was a prospective blind comparison to a reference standard. Pharmacy residency projects conducted at the study institution between 2001 and 2012 were included. A step-wise, systematic procedure containing up to 8 search strategies in PubMed and EMBASE for each project was created using the names of authors and abstract keywords. In order to further maximize sensitivity, complex phrases with multiple variations were truncated to the root word. Validity was assessed by obtaining information on publications from an online survey deployed to residency graduates.
The search strategy identified 13 publications (93% sensitivity, 100% specificity, and 99% accuracy). Both methods identified a similar proportion achieving publication (19.7% search strategy vs 21.2% survey, P = 1.00). Reliability of the search strategy was affirmed by the perfect agreement between 2 investigators (k = 1.00).
This systematic search strategy demonstrated a high sensitivity, specificity, and accuracy for identifying publications resulting from pharmacy residency projects using information available in residency conference abstracts.
To systematically search the literature for trials evaluating luminal toxin-binding agents (LTBAs) for Clostridium difficile infection (CDI).
A systematic search was conducted utilizing PubMed and International Pharmaceutical Abstracts with the following terms: anion-exchange resins, C difficile, cholestyramine, tolevamer, and colestipol. Articles were included if published in the English language and reported clinical outcomes of more than 5 adult humans with CDI treated with LTBAs.
Nearly all clinical trials evaluated LTBA as monotherapy for CDI and LTBAs are inferior to standard therapy. In contemporary practice, LTBAs are employed as adjunctive or sequential therapy for which there is a paucity of data. Some data suggest potential efficacy for recurrent CDI. Current guidelines for CDI assert LTBAs are contraindicated due to drug–drug interactions with vancomycin. However, the impact of this interaction on clinical outcomes has not been evaluated, and it is unknown whether higher doses of vancomycin or separating the administration of LTBAs from vancomycin would mitigate this interaction.
LTBA monotherapy is inferior to vancomycin and metronidazole for CDI. Some data indicate possible benefit in reducing recurrent CDI, but outcomes with adjunctive and/or sequential LTBAs are unavailable. Further studies are needed to investigate the role of LTBAs for CDI.
To determine the methods used by pharmacists in academia to estimate kidney function for antimicrobial dosing.
Stratified by region, a random sample of Accreditation Council for Pharmacy Education recognized Colleges of Pharmacy was selected for a total of 40 programs. Identified college Web sites were reviewed for eligible participants using the predefined inclusion/exclusion criteria. This was used to create a sampling frame from which 30% and 20% of faculty were randomly chosen and invited to participate via e-mail and mail-administered surveys, respectively.
Of the responders, 86% (31 of 36) who routinely estimate kidney function utilized the Cockcroft-Gault (CG) equation. In obese patients, 75% utilized the CG equation with or without adjustments. In patients ≥65 years, 42% adjusted serum creatinine to 1 mg/dL and 25% did not make any modifications. The majority of the responders accounted for patients with quadripalegia or bed-bound patients when estimating kidney function. In scenario examples, 51% (18 of 35) dosed an elderly female and 51% (18 of 35) a morbidly obese female as creatinine clearance ≥50 mL/min; however, 49% (17 of 35) did not.
The majority of responders utilized the CG equation for estimating kidney function with or without adjustments. Although a number of consistencies were noted, discrepancies existed, especially with elderly and obese patients.
This investigation evaluated the incidence, severity, and harm of adverse drug reactions (ADRs) associated with antipsychotic use for intensive care unit (ICU) delirium.
In this prospective, observational study patients were screened for development of delirium with the Intensive Care Delirium Screening Checklist (ICDSC). An ICDSC score of
Of 90 patients with delirium, 56 received antipsychotics. Ten suspected ADRs occurred attributed to antipsychotic use. QTc prolongation was the most observed ADR (50%). Patients with ADRs had higher mean Acute Physiology and Chronic Health Evaluation II (APACHE II) scores (P = .038). Patients who received haloperidol experienced more severe (P = .048) ADRs.
ADRs were observed in 18% of patients having delirium treated with antipsychotics with about half considered severe or harmful. A risk versus benefit assessment is needed before initiating antipsychotic therapy in ICU patients.
To assess knowledge and perceptions of health care workers regarding optimal care for patients with hyperglycemia and identify commonly perceived barriers for the development of a hospital-wide education program.
A cross-sectional design was utilized to survey health care workers involved in managing hyperglycemia in an urban, community teaching hospital. Each health care worker received a survey specific to their health care role.
Approximately 50% of questions about best clinical practices were answered correctly. Correct responses varied across disciplines (n, mean ± standard deviation [SD]), that is, physicians (n = 112, 53% ± 26%), nurses (n = 43, 52% ± 35%), pharmacists (n = 20, 64% ± 23%), dietitians (n = 5, 48% ± 30%), and patient care assistants (n = 12, 38% ± 34%). Most health care workers perceived hyperglycemia treatment to be very important and that sliding scale insulin was commonly used because of convenience but not efficacy.
Knowledge regarding hyperglycemia management was suboptimal across a sample of health care workers when compared to clinical best practices. Hyperglycemia management was perceived to be important but convenience seemed to influence the management approach more than efficacy. Knowledge, perceptions, and barriers seem to play an important role in patient care and should be considered when developing education programs prior to implementation of optimized glycemic protocols.
The purpose of this study was to survey new enrollees in a community pharmacy, employer-based diabetes and hypertension coaching program to describe the characteristics, health beliefs, and cues to action of newly enrolled participants.
A 70-question, 5-point Likert-type survey was developed using constructs from the Health Belief Model (HBM), Theory of Planned Behavior (TPB), and Theory of Reasoned Action (TRA). New enrollees in the coaching programs completed the survey. Survey responses between controlled and uncontrolled patients and patient demographics were compared.
Between November 2011 and November 2012, 154 patients completed the survey. Patients were fairly well controlled with a mean hemoglobin A1C of 7.3% and a mean blood pressure of 134/82 mm Hg. The strongest cue to action for enrollment was the financial incentives offered by the employer (mean: 3.33, median: 4). White patients were significantly more motivated by financial incentives. More patients indicated they had not enrolled previously in the program because they were unaware it was available (mean: 2.89, median 3.0) and these patients were more likely to have an uncontrolled condition (P ≤ 0.050).
A top factor motivating patients to enroll in a disease management coaching program was the receipt of financial incentives. Significant differences in HBM, TPB, and TRA responses were seen for patients with different demographics.
The 2005 American Thoracic Society/Infectious Diseases Society of America (ATS/IDSA) guidelines for hospital-acquired pneumonia (HAP), ventilator-associated pneumonia (VAP), and health care-associated pneumonia (HCAP) stress the importance of initiating prompt appropriate empiric antibiotic therapy. This study’s purpose was to determine the percentage of patients with HAP, VAP, and HCAP who received guideline-based empiric antibiotic therapy and to determine the average time to receipt of an appropriate empiric regimen.
A retrospective chart review of adults with HAP, VAP, or HCAP was conducted at a community hospital in suburban Birmingham, Alabama. The hospital’s electronic medical record system utilized International Classification of Diseases, Ninth Revision (ICD-9) codes to identify patients diagnosed with pneumonia. The percentage of patients who received guideline-based empiric antibiotic therapy was calculated. The mean time from suspected diagnosis of pneumonia to initial administration of the final antibiotic within the empiric regimen was calculated for patients who received guideline-based therapy.
Ninety-three patients met the inclusion criteria. The overall guideline adherence rate for empiric antibiotic therapy was 31.2%. The mean time to guideline-based therapy in hours:minutes was 7:47 for HAP and 28:16 for HCAP. For HAP and HCAP combined, the mean time to appropriate therapy was 21:55.
Guideline adherence rates were lower and time to appropriate empiric therapy was greater for patients with HCAP compared to patients with HAP.
To review the evidence of an association between olmesartan medoxomil and symptoms mimicking celiac disease.
Literature was searched in PubMed (1965-November 2013) using the key words or MeSH terms olmesartan, enteropathy, celiac disease, sprue, and diarrhea. References from the Food and Drug Administration (FDA) and Dipiro’s Pharmacotherapy eighth edition textbook were also reviewed.
There have been recent implications of olmesartan medoxomil being linked to symptoms mimicking celiac disease. Investigators first identified the association in 22 patients who presented with presumed refractory celiac disease. Upon further evaluation, it was discovered that these symptoms improved when olmesartan was discontinued. In response to this report, additional case studies have been published. DeGaetani et al also further analyzed patients with seronegative villous atrophy from the Celiac Disease Center and found that olmesartan accounted for 22% of previously unclassified sprue cases. Conversely, the authors of the ROADMAP trial, which compared olmesartan to placebo, found no significant differences in the incidence of gastrointestinal adverse effects.
There is growing evidence supporting the association between olmesartan and sprue-like symptoms; however, further research is warranted. These symptoms can be life threatening and clinicians should be aware of the potential association.
The incidence and mortality of melanoma are on the rise. Historically, patients diagnosed with metastatic melanoma were faced with a grim prognosis, with survival rates of 15% at 5 years. Prior to 2011, no drug or therapeutic regimen had been shown to improve overall survival (OS) in metastatic melanoma. Chemotherapeutic agents, such as dacarbazine or temozolomide, are often given to patients for palliative purposes; high-dose interleukin 2 and biochemotherapy are immunotherapeutic options that could be offered to patients with a good performance status at specialized centers. Neither has been shown to impact OS, but durable complete responses are seen in a minority of patients. Since 2011, 4 new drugs have been approved by the US Food and Drug Administration for the treatment of metastatic melanoma, all of which improve survival. Three of these agents (vemurafenib, dabrafenib, and trametinib) are targeted therapies, with ipilimumab being the only new immunotherapy. With a focus on immunotherapeutic agents, this review seeks to summarize the treatment options currently available for metastatic melanoma and to examine those on the near horizon.
To examine the factors impacting postgraduate year 1 (PGY1) residents’ self-perceived readiness for residency.
A total of 1801 residents who matched in American Society of Health-System Pharmacists (ASHP)-accredited PGY1 programs were e-mailed individualized invitations to take an online survey. The survey collected self-ratings of readiness for residency training competencies including time management and organization, foundational knowledge, clinical practice, project management, and communication. Key
Data from 556 completed surveys were analyzed. Residents agreed they were ready to perform activities requiring time management and organization (median = 4, mean = 4.08), foundational knowledge (median = 4, mean = 3.83), clinical practice (median = 4, mean = 3.67), and communication (median = 4, mean = 4.05). Residents who completed at least 1 academic advance pharmacy practice experience (APPE), 5 clinical APPEs, or held a bachelors degree felt more confident than their counterparts in regard to project management (P < .001, <.001, and .01, respectively).
PGY1 residents generally felt prepared for time management and organization, foundational knowledge, and communication residency training competencies. This was significant for those who completed 1 or more academic APPEs, 5 or more clinical rotations, or a bachelors degree. Study results may assist pharmacy schools in preparing students for residency training, prospective resident applicants in becoming more competitive candidates for residency programs, and residency program directors in resident selection.
Identify and summarize articles that describe the value that pharmacy residency training offers to sponsoring health systems.
There is a tremendous gap between the number of resident applicants and the number of pharmacy residencies available. Informing health-system administration executives about the proven value of residency training is key to expanding the number of available positions. To address this disparity, a comprehensive and systematic literature search to identify publications highlighting the value that pharmacy residency training provides to the sponsor hospital or health system was conducted. Articles were identified through query of PubMed and SciVerse SCOPUS and through review of bibliographies from relevant articles. Twenty articles were identified and summarized in this annotated bibliography that demonstrate perceived and quantitative value of pharmacy residency training for health systems that sponsor residency training.
Pharmacy residency training programs are essential for pharmacists that will primarily engage in direct patient care activities. This annotated bibliography includes key publications that provide evidence of the value that pharmacy residents provide to the sponsoring health system. This manuscript will aid prospective residency directors interested in developing new residency positions at new institutions or for residency program directors interested in expanding the total number of resident positions available at the existing sites.
Ketamine is a dissociative anesthetic and substance of abuse. Numerous effects can result from the abuse of ketamine. Death from acute direct toxicity is rare. Ketamine can alter numerous functions in the brain including color perception, memory, attention, cognition, reaction time, and sense of time and can produce psychological addiction. Chronic ketamine abuse can produce toxicity to the gastrointestinal and urinary tract. Gastrointestinal changes include epigastric pain, hepatic dysfunction, and impaired gallbladder activity. The most common urological condition from ketamine is cystitis but renal failure has been reported.
Recommendations for treatment of ventilator-associated pneumonia (VAP) emphasize early empiric broad-spectrum antibiotics. However, appropriate antibiotic de-escalation is also critical for optimal patient care.
We examined how often intensivists in our institution appropriately de-escalated antibiotics in cases of suspected VAP, and whether decision support by intensive care unit pharmacists could improve rates of antibiotic targeting and early antibiotic discontinuation in low-risk patients.
A total of 92 (observation phase = 50; intervention phase = 42) patients with suspected VAP were identified. During the observation phase, 39 cases yielded positive sputum cultures, but in only 23 (59%) were antibiotics targeted to culture results. This rate improved during the intervention phase when 29 (91%) of 32 cases with positive cultures were targeted (P value .003). There were 48 cases in which the risk of pneumonia was considered low. Of the 26 low-risk cases in the observation phase, 5 (19%) had antibiotics discontinued early versus 5 (23%) of the 22 cases in the intervention phase.
Decision support by clinical pharmacists significantly improved rates of appropriate antibiotic targeting in cases of culture-positive suspected VAP but did not have a significant effect on early antibiotic discontinuation in patients at low risk of true pneumonia.
To compare and contrast the characteristics of 2 groups of men ≥40 years old: reported anabolic–androgenic steroid (AAS) users and nonusers.
Cross-sectional survey.
Thirty-eight online fitness, weight lifting, bodybuilding, and steroid Web sites.
A total of 67 male AAS users and 76 male nonusers ≥40 years old.
Demographics, utilization of AAS and other performance-enhancing agents (PEAs), exercise patterns, history of illicit drugs and alcohol use, and psychiatric traits/diagnoses.
The majority of AAS users ≥40 years old were caucasian (92.5%), heterosexual (97.0%), and classified themselves as recreational exercisers (79.1%). AAS users took more PEAs (11.5 ± 5.6 vs 4.6 ± 2.7; P < .001), were more likely to binge drink (47.8% vs 29.0%; P = .025), report heavy alcohol use (21.0% vs 7.9%; P = .031), meet criteria for substance dependence disorder (27.4% vs 4.0%; P < .001), and report an anxiety disorder diagnosis (12.0% vs 2.6%; P = .046) than nonusers.
AAS misuse is prevalent among older men and is associated with polypharmacy, more aggressive alcohol use, and a higher incidence of substance dependence and anxiety disorders compared to nonusers. This information may help clinicians and researchers identify and develop appropriate intervention strategies for AAS abuse among older men.
This article identifies, prioritizes, and summarizes the published literature on the medication use process (MUP) from calendar year 2012 that can impact health-system pharmacists’ daily practice.
The MUP is the foundational system that provides the framework for safe patient care within the health care environment. The MUP is defined in this article as having the following components: prescribing/transcribing, dispensing, administration, and monitoring. A PubMed search was conducted in January 2013 for calendar year 2012 using targeted Medical Subject Headings (MeSH) keywords, providing a total of 944 articles. A thorough review identified 46 potentially significant articles: 14 for prescribing/transcribing, 12 for dispensing, 10 for administration, and 10 for monitoring. Peer review led to the selection of key articles from each category. These articles are briefly summarized, with a mention of why this article is important within health-system pharmacy. The other articles are listed for further review and evaluation.
It is important to routinely review the published literature and to incorporate significant findings into daily practice. Health-system pharmacists have an active role in improving the MUP in their institution and awareness of the significant published studies can assist in changing practice at the institutional level.
Quality-related events (QREs), including medication errors and near misses, are an inevitable part of community pharmacy practice. As QREs have significant implications for patient safety, pharmacy regulatory authorities across North America are increasing their expectations regarding QRE reporting and learning. Such expectations, commonly encapsulated as standards of practice (SoP), vary greatly between pharmacy jurisdictions and may range from the simple requirement to document QREs occurring within the pharmacy, all the way to requiring that quality improvement plans have been put in place. This research explores the uptake of QRE reporting and learning SoP and how this uptake varies based on pharmacy characteristics including location, prescription volume, and pharmacy type. Secondary data analysis of 91 community pharmacy assessments in Nova Scotia, Canada, was used to explore uptake of QRE standards. Overall, pharmacies are performing relatively well on reporting QREs. However, despite initial success with basic QRE reporting, community pharmacy uptake of QRE learning activities is lagging.
To investigate the potential cost savings of using functional platelet assays to confirm the diagnosis of heparin-induced thrombocytopenia (HIT).
This was a single-center study conducted in the United States. We performed a retrospective cost of illness analysis of suspected HIT, comparing patients with the serotonin release assay (SRA) ordered as part of their diagnostic evaluation to those who did not. The primary clinical end point was a composite of mortality and major bleed.
A total of 147 patients met the study’s inclusion criteria. An SRA was ordered in 53 patients of whom 17% were positive. Overall, SRA use did not reduce the composite primary clinical end point (32.1% vs 33%, P = .911). Also, there was no difference in the total cost of hospital stay (US $84781.1 vs US $78534.4, P = .409) nor in the direct medical costs related to HIT management (US $7473.5 vs US $8402.4, P = .393). Early ordering of the SRA (within 48 hours) was associated with shorter length of stay (20 vs 27 days, P = .029) but without a difference in cost of treatment.
The use of SRA did not reduce the costs or improve clinical outcomes in patients with suspected HIT.
Alogliptin is the newest dipeptidyl peptidase 4 (DPP-4) inhibitor approved for the treatment of type 2 diabetes either alone or in combination with other antidiabetic agents. The purpose of this review is to highlight the clinical studies that led to Food and Drug Administration approval of alogliptin and to provide insight into the place in therapy for the management of type 2 diabetes mellitus.
As a DPP-4 inhibitor, alogliptin raises postprandial levels of glucagon-like peptide 1, leading to insulin secretion and glucose homeostasis. When given as monotherapy, alogliptin has the ability to reduce glycoslate hemoglobin A1c (HbA1c) by 0.4% to 1.0%. Combination therapy yielded similar reductions with some variability depending on the agent with which alogliptin was combined. The mean HbA1c reduction seen with alogliptin is relative to the degree of HbA1c elevation at baseline. Alogliptin appears to be weight neutral and is relatively well tolerated with few adverse effects. Furthermore, alogliptin has proven to result in comparable efficacy and tolerability in the elderly as in the younger population.
Alogliptin alone or in combination with other antidiabetic agents has shown a significant reduction in HbA1c while remaining safe and tolerable. The efficacy profile of alogliptin is comparable to other DPP-4 inhibitors. Additional long-term research is necessary with regard to long-standing efficacy and effects on beta-cell function.
Prescription opioid (PO) abuse has reached epidemic proportions in the United States, and pharmacies are locations from which these medications are often diverted. This study identifies factors associated with pharmacists who currently screen and discuss PO misuse with patients.
A secondary data analysis of a cross-sectional Web-based survey that was sent to pharmacists was conducted. The survey contained items that assessed whether pharmacists currently screened and discussed PO misuse with patients along with pharmacists’ attitudes and beliefs toward providing brief interventions. Multivariable models were developed which identified factors associated with pharmacists’ currently screening and discussing misuse.
Chain setting pharmacists (odds ratio [OR] = 6.16, 95% confidence interval [CI] = 1.16-32.72) and pharmacists interested in being directly involved in PO screening and brief intervention research projects (OR = 2.06, 95% CI = 1.35-3.15) were most likely to report current screening. Pharmacists who reported currently screening for misuse (OR = 4.27, 95% CI = 2.83-6.45) and who reported wanting to help patients who misuse POs (OR = 3.03, 95% CI = 1.50-6.15) were most likely to currently discuss abuse.
Investigators implementing pharmacy-based screening and brief intervention studies for POs should take into account practice location and pharmacists’ interest in addressing PO issues.
Although antiplatelet therapy is a mainstay of post–percutaneous coronary intervention therapy, pharmacogenetic (PGt) considerations of therapy are often ignored despite related Food and Drug Administration warnings. Pharmacists are well situated to provide PGt guidance, and the community pharmacy is one setting where PGt testing, interpretation, and recommendations can take place to ensure optimal therapeutic outcomes.
A 65-year-old man who had a myocardial infarction that was treated with PCI and stent placement was determined by a community pharmacist to be a candidate for PGt testing to ensure optimal antiplatelet therapy. The patient was seen in the pharmacy as a part of a medication therapy management encounter and underwent genetic testing. Results of the genetic testing indicated the need for modification of therapy. The community pharmacist interpreted the results and made the appropriate recommendation to the cardiologist who in turn modified antiplatelet therapy appropriately.
This case describes the potential for collaboration between pharmacists and physicians to optimize antiplatelet therapy through PGt testing. Points of consideration for others looking to implement related PGt services are also discussed.
The objectives of this study were to (1) examine the relationships between Emotional Thinking Scale (ETS) scores and demographic variables such as income, years worked as a pharmacist, and hours worked per week and (2) determine the distribution of ETS scores among this sample of pharmacists. These objectives are significant to explore because they may provide important data regarding effective and ineffective pharmacist work-related behaviors that affect career and life success.
A convenience sample of practicing pharmacists was selected. Participants completed the 8-item ETS and a demographic survey. The ETS predicts how an individual’s thoughts might influence his or her emotions and behaviors. Researchers analyzed participant’s ETS scores with his or her demographic responses. Data were analyzed using SPSS statistical software.
One hundred twenty-five pharmacists completed the survey. Twenty-one percent of the sample scored between slightly high and very extremely high on the ETS. "often being incapacitated by strong feelings" correlated negatively with annual income r = –.309 (P = .008); "relying on feelings to deal with complex situations" correlated negatively with annual income r = –.253 (P = .026), with the "number of years practicing pharmacy" r = –.317 (P = .007), and "number of hours worked each week" r = –.317 (P = .007); and "focusing on details thus losing the big picture" was correlated negatively with annual income r = .215 (P = .05). These findings are consistent with the previous ETS research.
The variables of interest in this study were negatively but significantly related. Emotional thinking scores decreased with pharmacy practice experience and may be counterproductive for career goals. Entry-level pharmacy education and continuing education programs may help develop self-awareness to this issue.
Describe the rate of compliance with institutional antimicrobial dosing guidelines in patients on concomitant continuous venovenous hemodialysis (CVVHD).
This single-center retrospective chart review evaluated adult patients receiving concomitant intravenous antimicrobials and CVVHD for at least 24 hours over a 2-month period.
A total of 42 patients, 76 antimicrobial courses, and 208 study days (24 hours of concomitant therapy) were evaluated. Overall, antimicrobials were dosed according to the institutional guidelines on 162 (78%) of 208 study days. All nonconcordant doses were below recommendations. The recommended dose was never received prior to antibiotic or CVVHD discontinuation in 22% of the cases. In cases where antimicrobials were initiated when the patient was already on CVVHD, 74% of the initial doses met guideline criteria. Pharmacist recommendation was associated with increased dosing compliance (94% vs 73% of study days, P = .001). During transition from CVVHD to intermittent hemodialysis (IHD), only 62% of antimicrobial doses were decreased by the first IHD day.
Antimicrobial dosing in patients on CVVHD was below institutional guideline recommendations in many cases. Pharmacist recommendation was associated with compliance. Centers should evaluate their own compliance rate with institutional guideline recommendations for CVVHD and implement initiatives to improve dosing practices.
To develop and implement a research elective course to enhance skills of pharmacy students on primary literature evaluation and evidence-based practice on dietary supplements and generate scholarly publications.
A 2 credit hour independent research elective course was designed and implemented in the third-year doctor of pharmacy curriculum. The course involved student-led research activities that included formulating research project, reviewing of primary literature, collection and evaluation of data, and writing of review articles for publication in peer-reviewed journals. An online survey was administered to evaluate students’ perceptions of the course.
Students successfully completed the course. The course resulted in peer-reviewed publications through student–faculty collaboration. Pharmacy students enrolled in the elective course perceived that the course helped them enhance their analytical reasoning, critical thinking and drug-literature evaluation skills, gain evidence-based knowledge, and apply the knowledge into practice during their advanced pharmacy practice experiences community pharmacy rotations.
The course provided opportunity to the pharmacy students to not only critically search and evaluate the literature but also publish in peer-reviewed journals. Other pharmacy schools/colleges can adopt this course model to create opportunities for student–faculty collaborations toward scholarly accomplishments.
Neurologic trauma, which consists of acute spinal cord injury and traumatic brain injury, is a leading cause of death and disability. In recent years, there have been improvements in the early recognition and prompt resuscitation of patients with neurologic trauma. However, there remain few pharmacologic treatments to reduce its secondary complications. Corticosteroids have been used in patients with neurologic trauma for more than 5 decades. Traditionally, their use has been to improve motor and sensory recovery. However, recently their utility to prevent and manage trauma-related pneumonia has been investigated. Given these new investigations, the purpose of this review article is to provide a comprehensive overview of the history and available scientific evidence surrounding the use of corticosteroids in neurologic trauma and caution against the use of these agents to prevent hospital-acquired pneumonia in this patient population.
To evaluate the provisions made by pharmacists when dispensing an emergency supply of an antihypertensive medication to patients in a community setting.
Pharmacists and nonpharmacists (pharmacy technicians or interns) who were employed with community pharmacies and have witnessed or dispensed an emergency supply of an antihypertensive medication. Those who agreed to participate in this study via informed consent.
A short questionnaire was used to assess the provisions made by community pharmacists from the perspectives of both the pharmacists and the nonpharmacists.
Availability of blood pressure machines, evaluation of blood pressure readings, and patient counseling sessions or assessments prior to dispensing the emergency supply of an antihypertensive were the major outcome measures.
Among the participants, 92% of the pharmacists and 79% of the nonpharmacists reported they have witnessed or dispensed an emergency supply of an antihypertensive medication. Of those, 82% of the pharmacists and 78% of the nonpharmacists recognized there were blood pressure machines available. However, 78% of the pharmacists and 72% of the nonpharmacists acknowledged the patient’s blood pressure was not checked.
This observational study demonstrates that provisions when dispensing an emergency supply of an antihypertensive medication are inconsistent. Further evaluation is warranted.
Introduction: Nonprescription emergency contraception (EC) is now available for purchase without age restrictions. This is a great opportunity for pharmacists to provide counseling to ensure that customers use EC correctly. Objective: This pilot study explored the impact of student pharmacist counseling on customer knowledge of EC in a retail pharmacy setting and assessed customer satisfaction with the counseling. Methods: Counseling was performed at 2 retail pharmacies during June and July 2012. Participants completed a 12-question pretest that measured baseline knowledge of EC prior to a 5- to 10-minute education session, followed by the same 12-question posttest. A follow-up test was conducted via telephone within 1 to 3 months after the counseling. Results: Eighty-seven women participated with a mean age of 30.2 (standard deviation = 7.2) years. The average posttest score was significantly higher than the pretest score (11.5 ± 1.0 vs 8.5 ± 2.5; P < .001). The mean follow-up score (9.9 ± 1.1) was significantly higher than the pretest score (P = .014), which indicated retained knowledge. Participants reported being highly satisfied with the counseling session and strongly agreed that the counseling would help them use EC correctly. Conclusion: Student pharmacist-provided EC counseling increased participants’ EC knowledge both immediate and long term. This study suggests that EC counseling is feasible and valued by customers.
Rhabdomyolysis is not a well-understood adverse effect of antipsychotic use. Proposed mechanisms suggest involvement of serotoninergic and/or dopaminergic blockade. The purpose of this study was to describe the relationship between antipsychotic use and rhabdomyolysis. Patients admitted with rhabdomyolysis and taking an antipsychotic from January 2009 to October 2011 were included. Background demographics, laboratory data, medical and physical history, concomitant medications, and hospital course data were collected. Of the 673 cases admitted with rhabdomyolysis, 71 (10.5%) were on an antipsychotic. This is significantly greater when compared to the general US population, where only 1.3% of individuals take an antipsychotic drug (P < .0001). Cause of rhabdomyolysis was not documented in 38% of cases, and antipsychotic use was suspected in 10% of cases. No significant correlations were found between antipsychotic type and other patient-specific parameters. Seventeen (25%) of these patients were taking 2 or more antipsychotics. The largest percentage was on quetiapine (Seroquel®; AstraZeneca, Wilmington, Delaware), the most commonly prescribed antipsychotic in the United States. Antipsychotic use is a risk factor for rhabdomyolysis and seems to be more common in those taking multiple agents. More research needs to be done to determine which antipsychotics have a higher risk and which receptors are involved. Providers should be aware of rhabdomyolysis associated with antipsychotic use.
Insulin improves glycemic control in several ways, for example, by stimulating glucose uptake in the muscle and inhibiting hepatic glucose production. It has other mechanisms of action for correcting the abnormal metabolism of proteins, fats, and carbohydrates. The formulation of concentrated insulin (U-500) is a higher potency of insulin than the U-100 regular formulation. It is indicated for children and adults with type 1 and type 2 diabetes who have not achieved adequate glycemic control with exercise and proper dietary habits. However, the unique characteristics of concentrated insulin require that a patient be educated on its use. This article provides a practical guide for pharmacists on the use of concentrated insulin in both inpatient and outpatient settings and highlights specific concerns and management strategies.
Concentrated insulin works in the same mechanism as U-100 insulin formulations for treating type 1 and type 2 diabetes. Pharmacists are knowledgeable about managing the disease and can identify patients who will benefit with treatment of concentrated insulin. They can provide recommendations to prevent and resolve situations, such as dosing errors, which arise in patients on concentrated insulin and can educate patients and health care professionals on dosing conversions and titration.
Antimicrobial stewardship programs are mainly established by infectious diseases physicians and infectious diseases-trained clinical pharmacists with the goal of optimizing patients’ outcomes while halting antimicrobial resistance, decreasing adverse events, and controlling health care cost. The role of the infectious diseases-trained clinical pharmacist in antimicrobial stewardship is well established; however, there are not enough formally trained pharmacists to assume the challenging responsibilities of the steward coordinator. The purpose of this article was to review the available literature and resources and propose a model to engage introductory pharmacy practice experience students, advanced pharmacy practice experience students, postgraduate year (PGY) 1 pharmacy residents, PGY2 infectious diseases pharmacy residents, and PGY2 or PGY3 infectious diseases pharmacy fellows in antimicrobial stewardship. Further studies are needed to assess and document the impact of pharmacy students and postgraduate trainees on antimicrobial stewardship programs.
The study objectives were to evaluate the correlates and outcomes of a parenteral (IV) to oral (PO) antimicrobial conversion program at a Midwest US Academic Medical Center with the hypothesis that it will be associated with reduced drug costs. Patient-level data (n = 237; sex, race, admission source, admission status, admission severity, risk of mortality [relative expected, admission], and early death) were extracted from the Clinical Data Base/Resource Manager. Medication-level, drug-encounter data (n = 317; antibiotic/dose/route/frequency/duration, conversion status, 10-day IV/PO switch-eligibility criteria) were extracted from patient’s hospital medical records. Univariate analyses using chi-square or Fisher’s exact test for categorical variables and Wilcoxon rank-sum test for continuous variables showed patients not converted (n = 149) versus converted (n = 88) at some point from IV to PO were more likely to be of white race and had higher risk of relative expected mortality. By applying the unit drug cost (derived from 2010 Thomson Reuters RED BOOKTM) and labor costs for IV/PO administration, both per dose, the overall 1-month drug cost-saving estimates in 2010 in US dollars were US$5242 from converting and US$8805 savings missed from not converting 518 and 1387 switch-eligible antibiotic doses, respectively. Despite sample-size limitations, this study demonstrated correlates and missed opportunities to convert antimicrobials from IV to PO, which warrants providers’ attention.
The concurrent use of cigarettes while on warfarin therapy is a common occurrence. Smoking cessation among patients on chronic warfarin therapy is suspected to reduce drug clearance that may require dose adjustments. This type of interaction is particularly important when dealing with narrow therapeutic medications, as is the case with warfarin. Our case describes a series of supratherapeutic international normalized ratios (INRs) due to smoking cessation while on concomitant warfarin therapy.
A 51-year-old male presented to the anticoagulation clinic for management of his warfarin therapy for an acute deep vein thrombosis. After 2 months of stable, therapeutic INR levels, the patient abruptly decreased his smoking from 1 pack/day to one-half pack/day and then subsequently stopped smoking completely. The patient’s smoking cessation resulted in a major modification of his required weekly warfarin dose to maintain a therapeutic INR (a 39% dose reduction).
This case exemplifies how certain lifestyle factors, such as smoking, can alter the pharmacokinetics of patients on chronic warfarin therapy. This is the first case to demonstrate a greater than 30% reduction in the weekly warfarin dose following smoking cessation.
In July 2013, the US Federal Drug Administration approved levomilnacipran extended release (ER; Fetzima), a serotonin-norepinephrine reuptake inhibitor, for the treatment of adults with major depressive disorder. Levomilnacipran is an active enantiomer of the racemic drug milnacipran that is currently approved in the United States for the treatment of fibromyalgia. This article provides an overview of the mechanism of action, pharmacokinetic properties, clinical efficacy, safety, and tolerability of levomilnacipran ER. Relevant information was identified through a search of databases using the key word levomilnacipran. Additional information was obtained from fda.gov, by a review of the reference lists of identified articles, and from posters and abstracts from scientific meetings. Levomilnacipran ER, dosed once daily, is generally well tolerated and has demonstrated favorable effects compared to placebo in clinical trials of patients with major depressive disorder. The increased potency for norepinephrine reuptake inhibition is a characteristic that may represent a novel contribution for levomilnacipran. Additional studies comparing levomilnacipran ER to other commonly prescribed antidepressants are needed to further evaluate its place in therapy.
The purpose of this review was to evaluate the literature to assess the incidence and true clinical relevance of recent Food and Drug Administration warnings regarding QT prolongation with azithromycin, given its widespread use, with over 40 million US outpatient prescriptions written in 2011. A literature search of MEDLINE (1946 to May 2013) and International Pharmaceutical Abstracts (1970 to May 2013) was conducted using the terms azithromycin, QT prolongation, torsades de pointes, arrhythmia, and cardiovascular death. A bibliographic search was also performed. Several relevant studies and case reports were identified and reviewed. One cohort study revealed an increased risk of cardiovascular death with azithromycin compared to no antibiotic, especially in those with higher cardiovascular risk. Another cohort study comparing azithromycin, penicillin V, and no antibiotic in a younger Danish population with less cardiac risk found no increased cardiovascular death associated with azithromycin use. The majority of case reports involved ill and/or elderly patients with multiple comorbidities and concomitant medications who were already at a higher risk of cardiovascular events. Although there is evidence that azithromycin may induce QT prolongation and adverse cardiac events, the incidence is fairly limited to patients with high baseline risk, including those with preexisting cardiovascular conditions and concomitant use of other QT-prolonging drugs.
The safety and efficacy of warfarin depend on maintaining the international normalized ratio (INR) in an established range.
The purpose was to determine whether a coordinated pharmacist-led approach improved percentage of INRs in therapeutic range in comparison to a physician-led anticoagulation management service (AMS).
A retrospective chart review was conducted for patients at a multisite primary care organization. INR data for patients receiving warfarin management by a physician were collected from December 1, 2009 to May 31, 2010. These were compared to INR results from December 1, 2010 to May 31, 2011, during which patients received warfarin management from a pharmacist. The primary end points were percentage of INRs within a goal range of 2.0 to 3.0 and an expanded goal range of 1.8 to 3.2 for the physician-led group versus the pharmacist-led group.
The percentage of INR results within the goal range (2.0-3.0) was greater among patients in the pharmacist-led group (n = .130) than the physician-led group (n = 96; 57.5% vs 50.0%, respectively; P = .0004). The percentage of INR results <1.5 (7.3% vs 5.1%) and >3.5 (11.4% vs 7.1%) was also statistically significant in favor of the pharmacist-led AMS, with P values of .03 and .0004, respectively.
A pharmacist-led AMS improved the percentage of INRs in range, with significantly less out-of-range results.
Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely consumed drugs throughout the world for pain relief. Although the adverse effects of NSAIDs to the liver are well known, flurbiprofen-induced liver cholestasis is extremely rare. Herein, we present a patient with prolonged icterus that is associated with the use of flurbiprofen without causing ductopenia.
This pilot study explored the use of multidisciplinary high-fidelity simulation and additional pharmacist-focused training methods in training postgraduate year 1 (PGY1) pharmacy residents to provide Advanced Cardiovascular Life Support (ACLS) care. Pharmacy resident confidence and comfort level were assessed after completing these training requirements.
The ACLS training requirements for pharmacy residents were revised to include didactic instruction on ACLS pharmacology and rhythm recognition and participation in multidisciplinary high-fidelity simulation ACLS experiences in addition to ACLS provider certification. Surveys were administered to participating residents to assess the impact of this additional education on resident confidence and comfort level in cardiopulmonary arrest situations.
The new ACLS didactic and simulation training requirements resulted in increased resident confidence and comfort level in all assessed functions. Residents felt more confident in all areas except providing recommendations for dosing and administration of medications and rhythm recognition after completing the simulation scenarios than with ACLS certification training and the didactic components alone. All residents felt the addition of lectures and simulation experiences better prepared them to function as a pharmacist in the ACLS team.
Additional ACLS training requirements for pharmacy residents increased overall awareness of pharmacist roles and responsibilities and greatly improved resident confidence and comfort level in performing most essential pharmacist functions during ACLS situations.
Vancomycin is recommended as a first-line therapy for severe Clostridium difficile infection (CDI). Due to the high cost of commercially available vancomycin capsules, hospitals frequently compound oral solution despite a lack of data comparing outcomes. This study was conducted to determine treatment outcome differences based on oral vancomycin formulation.
Medical charts of 76 patients with an initial episode of severe CDI receiving oral vancomycin as a commercially available capsule or a compounded oral solution for at least 72 hours were retrospectively reviewed. The primary objective was to compare the time to clinical cure of CDI.
Baseline characteristics between groups were similar except for the median lactate, which was higher in compounded oral solution group (1.5 vs 0.6 mmol/L, P < .001). There was no difference in clinical cure at day 10 (64% solution vs 59% capsules, P = .664). Median time to clinical cure was 8 days for solution and 7 for capsules (P = .597). After adjustment, the hazard ratio of time to clinical cure for solution compared to capsules was 1.15 (P = .69). No significant differences in mortality, recurrence, or complications were noted.
Formulation of oral vancomycin did not impact treatment outcomes in this retrospective study.
The antifungal activity of echinocandins is concentration dependent. Previously, we demonstrated that high-dose caspofungin (HD-CSP; 100 mg daily) was well tolerated in 34 immunosuppressed patients with cancer and may have favorably influenced outcomes. We retrospectively assessed all 91 patients in whom HD-CSP was given for the treatment of invasive fungal disease (IFD). The median number of doses was 18.5 ± 21.5, and in 8 (9%) patients more than 40 doses were given. Most (62%) of the patients had leukemia. A total of 45 (49%) patients had undergone stem cell transplantation; 80% received allogeneic grafts and 47% had graft-versus-host disease. High-dose corticosteroids were given during antifungal therapy in 26 (29%) patients. In all, 8 (9%) patients had new elevation in serum bilirubin during HD-CSP therapy; normalization occurred after voriconazole and HD-CSP were discontinued in 4 patients each. No other short-term or delayed adverse events were observed. In all, 40 (44%) patients died of IFD. High-dose corticosteroids during HD-CSP (odds ratio [OR] 8, 95% confidence interval [CI] 2.1-30.4; P < .002) and starting HD-CSP in the critical care unit (OR 67.5, 95% CI 5.25-868.9; P < .001) were associated with death from fungal disease. Prolonged HD-CSP therapy was well tolerated. Drug-induced hyperbilirubinemia may pose a potential limitation for continued HD-CSP use in highly susceptible patients with hematologic neoplasms and stem cell transplantation.
To conduct a pilot study of a student-delivered academic detailing initiative to promote brief, pharmacy-based tobacco cessation interventions, and referrals to the tobacco quitline.
Pharmacy students (n = 11) received training and delivered academic detailing sessions for promoting brief tobacco cessation interventions at community pharmacies (n = 37). Six months after the session, a survey was faxed to each pharmacy to assess (1) the quality and acceptance of the academic detailing session and the materials provided during the session and (2) tobacco cessation counseling perceptions and practices.
Pharmacists from 30 (81%) sites responded to the survey; of these, 37% reported that they increased the number of patients asked about smoking since the academic detailing session, 70% reported an increase in the number of participants advised to quit smoking, 57% reported an increase in the number of patients counseled, and 50% reported routinely providing referrals to the tobacco quitline.
pharmacy students are capable of providing academic detailing for brief tobacco cessation interventions in community pharmacies. Results of this pilot study suggest a positive impact of this service on pharmacists’ counseling behavior for tobacco cessation.
The World Health Organization has estimated that as many as 450 million people worldwide have mental disorders. More than 44 million people in the United States have a mental disorder annually, estimating the annual direct costs of mental illness to exceed US$69 billion. Psychotherapeutic agents are used to treat mental illnesses and improve quality of life. The purpose of the study is to assess the knowledge and knowledge perception of community pharmacists and final-year student pharmacists regarding psychotherapeutic agents dispensed to their community of patients with mental illness.
A survey was distributed to pharmacists and final-year student pharmacists regarding psychotherapeutic agents.
In all, 100 pharmacists and 40 final-year student pharmacists completed the survey. Upon analysis of surveys returned by pharmacists, knowledge deficiency was assessed regarding anxiolytics and mood stabilizers. The analysis of student participant surveys demonstrated knowledge deficiency regarding antidepressants and anxiolytics.
Final-year student pharmacists would benefit from the curricular incorporation of courses and advanced pharmacy practice experiences in Psychiatry. Community pharmacists caring for customers with psychiatric disorders should take advantage of continuing education series that highlight updates and new developments regarding psychotherapeutic agents in order to improve clinical outcomes of patients.
To examine pharmacists’ self-reported competence in providing care to persons living with HIV (PLWH) and their HIV-related training and experience needs.
We interviewed 28 community-based pharmacists providing care to PLWH in 4 Midwestern cities. Results: Less than half (46%) of the pharmacists considered themselves competent to provide PLWH care, and less than a third (29%) worked with PLWH during their pharmacy residency. Specialty pharmacists need training on opportunistic infections and HIV-related comorbidities, nonspecialty pharmacists need general training in HIV treatment and patient communications skills, and all pharmacists require a mechanism to keep updated in the latest HIV treatment recommendations.
In the current era of patient-centered care, a pharmacist that is well rounded—not just in dispensing antiretroviral medications but highly knowledgeable in different aspects of ART and HIV-specific patient care—can make a valuable contribution to the health care team. Pharmacy school curricula and continuing professional education need to be aligned to meet the knowledge and competency needs of community pharmacists who are strategically positioned to provide care to PLWH.
The role of a pharmacist in achieving compliance with hospital core measures is described.
Core measures for hospitals, also known as quality measures, were introduced by the Department of Health and Human Services as an initiative to improve health care through accountability and public disclosure. Hospitals receive financial incentives for compliance with these core measures, but most importantly, these measures ensure that evidence-based therapy is consistently provided to each patient. If a core measure is not met, documentation must be provided to ensure that there is not a failure to meet the measure. Pharmacists were granted the authority to provide core measure documentation in 2007. There are a total of 44 core measures, 22 (50%) of which are medication related and can be documented by a pharmacist. Over a 5-year period, clinical pharmacists have recorded 1281 interventions for core measure documentation. In an analysis of a 1-year period of charts with missing core measure documentation, pharmacists prevented failure to meet the measure in 96% of the cases.
Given the great impact that pharmacists can have on hospital core measure compliance, each hospital’s Pharmacy Department should evaluate ways to improve involvement in the quality programs at their hospitals.
Calcium gluconate is preferred over calcium chloride for intravenous (IV) repletion of calcium deficiencies in the inpatient setting. In the setting of a national shortage of IV calcium gluconate, our institution implemented a compounded calcium chloride admixture for IV administration. The objective of this analysis is to evaluate the peripheral infusion site safety of compounded IV calcium chloride admixtures in adult inpatients. A total of 222 patients, encompassing 224 inpatient admissions, from April to June 2011 were retrospectively reviewed. Sterile preparations of calcium chloride in 5% dextrose (600 mg/250 mL and 300 mg/100 mL) were used during the study time period. Adverse infusion site reactions were assessed using an institutional infiltration and phlebitis grading system. A total of 333 doses were administered peripherally. In all, 4 (1.8%) patients experienced a moderate to severe infusion site reaction, with 3 due to phlebitis and 1 due to infiltration. Naranjo Nomogram for Adverse Drug Reaction Assessment classified all 4 reactions to have a possible link to calcium chloride administration. Peripheral administration of compounded calcium chloride admixtures in 5% dextrose is associated with a low incidence of IV infusion site reactions and can be considered as an alternative in the event of a calcium gluconate shortage.
Pharmacist-directed anticoagulation management services (AMSs) have been shown to significantly lower anticoagulation-related mortality, length of hospital stay, bleeding complications, blood transfusion requirements, and cost of therapy. AMSs are only 1 component of an anticoagulation stewardship program. Frequently, stewardship programs are limited to inpatient populations. Incorporating components that facilitate transition to outpatient status will ideally encompass complete care. The purpose of this program was to expand anticoagulation services and standardize care by implementing a full-service stewardship program including a transition of care service. The first component of the study involved medication surveillance for inpatients on anticoagulation therapy. The second component involved transitioning patients on anticoagulation, primarily with venous thromboembolism (VTE) to outpatient management. Finally, the pharmacist identified areas for optimization. Optimization involved developing or updating protocols to reflect updates in the literature as well as updating institution-specific information resources. Interventions made through medication surveillance and utilization of the VTE transition of care services translated into a total cost savings of approximately US$270 320. A postgraduate, first-year pharmacy resident contributed to improving patient outcomes while reducing utilization of hospital services and obtaining substantial cost savings through participation in anticoagulation stewardship services.
To compare the management of prediabetes between a family practice clinic and internal medicine/endocrinology practice.
A randomized, retrospective evaluation of the medical history in 168 eligible patients with a diagnosis of prediabetes or abnormal blood glucose (BG) at a family practice clinic (n = 78) and an internal medicine/endocrinology practice (n = 90).
The internal medicine/endocrinology practice provided more counseling regarding lifestyle modifications (91.1% vs 76.9%, P = .039), specific physical activity recommendations (26.7% vs 7.7%, P = .003), and recommended more patients receive 150 minutes/week of moderate exercise (8.9% vs 1.3%, P = .038). The family practice clinic provided more written dietary information (16.9% vs 13.3%, P = .044) and specific weight loss goals (20.5% vs 6.7%, P = .015). The internal medicine/endocrinology practice initiated pharmacological therapy in more patients (51.1% vs 3.8%, P < .001) and had a significant decrease in fasting BG from baseline compared to the family practice clinic (–9.0 vs –5.6 mg/dL, P < .001).
Providers are likely to initiate nonpharmacological therapy but may not provide specific education recommended by the American Diabetes Association. The integration of a multidisciplinary team to provide guideline-based nonpharmacologic counseling may be beneficial in improving outcomes in the management of prediabetes.
Knowledge of HIV serostatus is the first step to accessing treatment, reducing transmission, and mitigating public health challenges. We describe the expansion of an HIV point-of-care testing (POCT) program within a health care system utilizing pharmacists as testers. The testing program’s expansion is detailed and its impact assessed. The POCT program was evaluated by comparing the number of traditional HIV venipuncture tests to the number of POCTs performed across the health system as well as comparing the number of POCTs performed by clinical pharmacists to the number of tests at other POCT locations. Although pharmacists’ contributions to HIV prevention are well documented, pharmacists’ involvement in HIV testing initiatives is still nascent. Our POCT program demonstrates an effective HIV testing initiative driven by pharmacists and other health care providers.
Dabigatran etexilate, an oral direct thrombin inhibitor, was approved by the Food and Drug Administration to reduce the risk of stroke and systemic embolism in patients with nonvalvular atrial fibrillation based on the outcomes of the Randomized Evaluation of Long-term anticoagulant therapY (RE-LY) study. Although this study provides robust data on the efficacy and safety of dabigatran, there may be differences in the drug use and outcomes in routine clinical practice following drug approval. In this retrospective chart review study, we describe the use of dabigatran in 160 patients in 4 adult hospitals (1 academic and 3 community), including appropriate prescribing for indication, starting dose, concomitant anticoagulant and antiplatelet use, and clinical outcomes such as bleeding, myocardial infarction, and stroke. The study revealed appropriate indication of nonvalvular atrial fibrillation in 145 (91%) of the 160 patients. The dose of dabigatran was appropriate in 90% of the patients, with the most common cause of inappropriate dosing due to perceived bleeding risk. Over a follow-up period of 6 months, bleeding complications were noted in 6 patients still taking dabigatran, 5 of which were gastrointestinal bleeding. Our study underscores the importance of prescriber education regarding the appropriate indication, dosage, and safety of dabigatran with active participation of pharmacists in this process.
This project explores electronic mail (e-mail) as a potential medium for pharmacists to communicate pharmacotherapy interventions to prescribers.
This retrospective descriptive analysis was conducted at an urban, academic teaching hospital. The pharmacist attempted a drug therapy intervention via e-mail when unable to make face-to-face contact with the attending physician. Eligible patients for this project were admitted to the advanced heart failure (HF) team between December 1, 2010, and July 31, 2011, and had at least 1 attempted e-mail intervention. The primary outcome was the number of accepted interventions, while the secondary end point was the time until a physician e-mail response.
A total of 51 e-mail interventions were attempted on 29 patients (mean age = 53, 24% caucasian, 59% male, 69% left ventricular-assist device [VAD]). Overall, of the total 51 interventions,44 (86.3%) were accepted. The average time to a physician e-mail response was 41 minutes. Initiation of drug therapy and changing dose and route or frequency accounted for the most frequent intervention (33%). The most common drug classes involved in the e-mail interventions were angiotensin-converting enzyme inhibitors (15.7%), loop diuretics (9.8%), and antiplatelet agents (7.8%).
Clinical pharmacists with well-established physician relationships can effectively implement timely drug therapy recommendations using e-mail communications in patients with advanced HF or VADs.
To characterize the roles pharmacists have assumed in disasters and clarify the types of roles and disasters that may be less well-documented in the pharmacy literature.
This research examines how balanced or equally proportioned role categories are in the pharmacy literature, whether pharmacy journals differ in the proportion of role categories reported, and whether journals significantly differ in the proportion of reported chemical, biological, radiological, nuclear (CBRN), and natural disasters. Data coding was performed solely by the lead author using Concordance (Harvard University, Cambridge, Massachusetts), a Web-based content analysis software, and Minitab® (version 15; Minitab, Inc; State College, Pennsylvania) for descriptive and inferential statistical analysis. Pharmacy journals publishing at least 2 articles about pharmacist disaster roles from September 11, 2001 to September 30, 2011 were used in the study and were available electronically.
Chi-square analyses reveal significant differences in the weighted counts of roles, roles categorized by journal, and CBRN disasters categorized by journal.
Data suggest that pharmacists may be prepared to respond to hurricanes and biological and chemical disasters in pharmaceutical supply and patient management roles. Future research should highlight efforts to prepare health systems for the effects of nuclear, radiological, and chemical disasters.
The main objective was to evaluate whether the level of agreement of oncology hospital pharmacists with statements on their impact is influenced by the presence or absence of evidence-based data. The secondary objective was to evaluate the relative importance of evidence-based data among factors that may have contributed to oncology pharmacy practice evolution.
Oncology pharmacists’ answered a Web questionnaire to measure their level of agreement with statements regarding their impact. Respondents answered the questionnaire before (pre) and after (post) being informed whether supporting evidence was available for each statement. Respondents were also asked to rank all of the factors in order of their perceived contribution to oncology pharmacy practice evolution.
A total of 64 questionnaires were obtained. Respondents reported a high level of agreement with statements regarding their impact on oncology pharmacy practice (mean agreement of 95.9% pre vs 93.8% post). A statistically significant diminution in the level of agreement was observed for 3 statements after respondents were informed that no supporting evidence was available for these statements. Respondents assigned a high importance to factors related to the perception of positive outcomes of pharmaceutical activities on patient safety, health care costs, and clinical results but a low importance to the use of evidence-based data.
Antimicrobial stewardship programs are essential to health care institutions to promote the appropriate use of antibiotics not only to decrease antimicrobial resistance but to prevent the spread and infection of Clostridium difficile. Clostridium difficile–associated diarrhea is increasing rapidly in the United States and is now considered a major public health problem that poses an immediate threat to the health of patients prescribed antibiotics, more so than antimicrobial resistance. Clostridium difficile–associated disease is the result of collateral damage to the normal bacterial flora of the human body, which is an inevitable consequence of any antibiotic use. Antimicrobial stewardship programs such as audit with feedback and antibiotic restriction are designed to help limit Clostridium difficile infections and other hospital-associated organisms by optimizing antimicrobial selection, dosing, de-escalation, and duration of therapy. These programs also incorporate implementation of hospital-wide guidelines, staff education, enforcement of infection-control policies, and the use of electronic medical records when possible to help control antibiotic use. This article reviews the literature on how antimicrobial stewardship programs impact Clostridium difficile rates and discusses experiences in designing, implementing, monitoring, and follow-through of such programs.
The study objective was to determine which antimicrobials place patients at a higher risk for Clostridium difficile–associated diarrhea (CDAD) and which interventions can reduce their risk. All patients with diarrhea and a positive toxin assay for Clostridium difficile for 3 months were included in the study. Patients were broken down into either community-acquired infection or health care–associated infection based on symptom onset, antibiotic usage prior to admission, and where the patient was admitted from. Physicians were educated on antimicrobials that place patients at higher risk for CDAD and alternative agents to use. Physician education consisted of in-service presentations, posters, Medical Grand Rounds, and an article in the physician newsletter highlighting the initial results of this study and alternative antimicrobial regimens. After implementation of educational programs, a repeat sample of patients was reviewed to determine effectiveness of the physician education. Cases of CDAD increased secondary to testing changes at our facility. Implicated antimicrobial usage did decrease after educational program implementation.
For the treatment of Clostridium difficile–associated diarrhea (CDAD), metronidazole and vancomycin remain the most commonly used agents. The major advantage of metronidazole is its low cost, while the advantage of oral vancomycin is a more favorable pharmacokinetic profile. The epidemiology and clinical severity of CDAD have changed due to the emergence of a hypervirulent strain (BI/NAP1/027). In 2010, the Infectious Diseases Society of America/Society for Health Care Epidemiology of America expert panel defined severe CDAD and recommended oral vancomycin to treat these patients. Metronidazole remains the preferred agent for treatment of mild to moderate CDAD.
Poor compliance with antihypertensive medications is one possible reason why its success in clinical trials has not been translated into everyday practice. In addition, medication noncompliance in elderly leads to increased hospitalizations, physician visits, and higher health care costs.
The study assessed influence of illness perceptions and medications beliefs on medication compliance of elderly hypertensive cohorts.
A cross-sectional survey research design, utilizing self-administered health surveys, was adapted to address key study objectives. Conceptualized associations among the study variables were explored to assess their individual as well as their collective impact on the medication compliance.
A total of 78 (66%) study samples were found to be noncompliant with their medications. Analysis revealed that perceptions about illness and beliefs about medication jointly played a significant role in the prediction of medication compliance (F = 5.966, P < .05; R 2 = .212). Significant bivariate correlations were observed between Morisky’s test score versus Brief Illness Perception Questionnaire measure (r = .332, P = .001), Beliefs of Medication Questionnaire (BMQ) differential score (r = .301, P = .001), and BMQ components, such as specific necessity (r = .250, P = .008), specific concern (r = –.231, P = .001), and general overuse (r = –.342, P = .001).
The findings provide practical basis for designing interventions and programs aimed at compliance building in elderly populations having hypertension by incorporating the value and importance of patient perceptions of illness and medications in order to achieve desired patient outcomes.
Objective: To calculate the return on investment (ROI) for a targeted medication intervention program developed by corporate management of a community pharmacy. Design: Retrospective analysis and cross-sectional survey. Setting: Regional community pharmacy chain in North Carolina. Participants: Targeted medication interventions completed from February 1, 2010, to July 31, 2010, were included in the retrospective analysis. Community pharmacists employed by the pharmacy chain that completed the questionnaire were included in the cross-sectional analysis. Intervention: Targeted medication intervention services were provided to the patient and documented by the pharmacist. Main Outcome Measure: The ROI for a community pharmacist-provided targeted medication intervention program. Results: Of the 180 pharmacists, 69 completed the questionnaire (38% response rate). The average time to complete one targeted medication intervention was calculated to be 22.63 minutes. The total cost for providing a targeted medication intervention program during the study time frame was $15 760.86. Total revenue was $15 216.00; therefore, the program resulted in an ROI to the pharmacy chain of negative 3%. Conclusion: This 6-month study resulted in an ROI to the pharmacy chain of negative 3%. Under the current reimbursement model, for this program to break even, the average time to complete one targeted medication intervention must equal 21.85 minutes or less.
The Lebanese American University (LAU) offers first-year pharmacy students with Introductory Pharmacy Practice Experience (IPPE) courses comprising various activities that provide students with direct patient contact so that they can be geared up for "real-world" pharmacy practice. Routine assessment and improvement in these courses are imperative to ensure efficiency of these courses. This study was conducted to evaluate the quality of our IPPEs courses, determine its impact on student learning and satisfaction, and identify shortcomings in the program for quality improvement purposes.
A literature review-based questionnaire, consisting of 76 questions with a response options following a 4-point scale (strongly agree = 4 to strongly disagree = 1), was completed by 92 first professional year pharmacy students who finished their hospital and community IPPE at LAU.
The students reported a high degree of satisfaction in community and hospital sites in terms of site selection, program schedule, site and school preceptors, and overall satisfaction with the experience. Compared to the hospital setting, students practicing in the community reported significantly higher scores in overall satisfaction. Besides the high satisfaction rate, our results identified improvement measures in some aspects of the program.
Our IPPE program serves as a successful experiential learning for pharmacy students.
Many health systems have implemented interventions to reduce the rate of heart failure readmissions. Pharmacists have the training and expertise to provide effective medication-related education. However, few studies have examined the impact of discharge education provided by pharmacy students and residents on patients hospitalized with heart failure exacerbations.
This was a nonrandomized intervention study evaluating the impact of a pharmacy student and resident-led discharge counseling program on heart failure readmissions. The primary end point was the 30-day heart failure readmission rate. Secondary end points included self-reported patient understanding of medications, number of medication errors documented, and estimated associated cost avoidance.
A total of 86 and 94 patients were enrolled into the intervention and control groups, respectively. No statistically significant difference in readmission rates was detected between the intervention and the control groups. Thirty-four medication errors and discrepancies were documented, or 1 for every 2.5 patients counseled, resulting in an estimated cost avoidance of $4241 for the institution. Eighty-nine percent of patients who received discharge counseling agreed they had a better understanding of their medications after speaking with a pharmacy resident or student.
There was no statistically significant difference in readmission rates; however, several medication errors were prevented, and a large percentage of patients expressed an improved understanding of their medications.
This study intended to (1) describe the baseline patient satisfaction level and preferred coping strategies and (2) assess patient satisfaction and coping mechanisms pre- and postintervention. Patients on methadone maintenance treatment (MMT) in Terengganu, Malaysia, were randomized into either MMT or MMT plus auricular acupuncture (MMT + AA) groups. All received the standard MMT, while participants on MMT + AA underwent concurrent AA session thrice weekly for 2 months (each session = 30 minutes). Data analysis was carried out using SPSS 16.0, employing descriptive and nonparametric statistics. Participations were received from 97 eligible male patients (median age = 36.0 years; Malay = 97.9%). After screening for dropouts, only 69 patients were considered for subsequent analysis (MMT = 40; MMT + AA = 29). At preintervention, both groups did not differ significantly in the parameters investigated. During postintervention, no significant difference was detected for satisfaction level but coping-wise, substance use was significantly and frequently adopted by MMT + AA patients compared to MMT respondents (P < .05). On separate analysis, those who received MMT alone adopted active coping, venting, and self-blame significantly more frequently postintervention (P < .05). Nevertheless, no significant difference for coping styles of MMT + AA patients was exhibited over time (P >.05). The addition of AA therapy into the standard MMT treatment did not seem to influence patient satisfaction and their coping ways.
Venlafaxine is a serotonin norepinephrine reuptake inhibitor that is used for mood, anxiety, and pain disorders. We report a case of dose-related paresthesias in association with venlafaxine use in a patient with major depressive disorder. Case report: A young male patient with major depression started treatment with venlafaxine XR at 37.5 mg/d, and the dose was titrated to 75 mg/d with no significant adverse effects. Upon increasing the dose to 150 mg/d, the patient reported tingling, numbness, and itching in his upper extremities. The dose was reduced to 75 mg/d, at which time, the symptoms disappeared. Since the patient still had target symptoms of depression, the patient was willing to try increasing the dose back to 150 mg/d. Upon rechallenge, the tingling, numbness, and itching reappeared. The dose of venlafaxine was decreased back to 75 mg/d. Per the Naranjo scale, the probability score for the above adverse drug reaction is 5 (probable). We discuss the published evidence of paresthesias associated with antidepressants and clinical implications for recognizing paresthesias during venlafaxine treatment that may be useful for clinicians.
Clinicians need to be aware of the possible emergence of paresthesias with venlafaxine treatment, especially at doses of ≥150 mg/day. Patients who receive venlafaxine for pain disorders should be closely monitored for worsening of pain symptoms and may require adjustment of their doses.
To assess North Carolina pharmacists’ level of support for expanded authority to administer human papillomavirus (HPV) vaccines to identify concerns/benefits about expanded authority and to understand what factors predict support for expanded authority.
A 16-item electronic survey was e-mailed to all the pharmacists registered with the North Carolina Board of Pharmacy (n = 9502) between January and February 2011 (1600 pharmacists responded). The survey assessed HPV knowledge, level of support for expanded authority, and comfort level of HPV vaccine administration.
Many (64%) pharmacists were supportive of a rule change/legislation that would authorize pharmacists to administer HPV vaccines. Younger pharmacists were more supportive of expansion when compared to older pharmacists (r = –.138, P < .001). Pharmacists with higher knowledge scores were more supportive of expansion (r = .223, P < .001). Reporting a higher level of comfort in administering HPV vaccines at their pharmacy was significantly and positively correlated with higher level of support for expansion (r = .624, P < .001). In the multivariate analysis, HPV knowledge, comfort level in administering vaccine, patient age, and type of pharmacy were all predictive of higher level of support for expanded authority where employed.
A large proportion of pharmacists were supportive of an expanded role in providing HPV vaccines. Exploring alternate delivery mechanisms like this one is advantageous.
Warfarin is frequently used for the prevention and treatment of thromboembolism, yet it is associated with numerous drug interactions. Regarding over-the-counter pain medications, the preferred analgesic for those patients who are taking warfarin is acetaminophen. There are, however, reports of elevation in the international normalized ratio (INR) in those patients taking concurrent warfarin and acetaminophen. For those practitioners who manage warfarin therapy, there is little guidance regarding management of the drug–drug interaction between warfarin and acetaminophen. This review seeks to evaluate the drug interaction between warfarin and acetaminophen and provides recommendations for concurrent use of these drugs.
The aim was to compare nursing staff compliance over the years, per health care unit, and per drug use process step.
Compliance assessment was performed by nursing consultants with direct observation of the registered nurses and nursing assistants during the performance of 7 steps of the drug use process. A total of 36 compliance criteria were developed. The compliance to drug use process criteria was measured in 2007 (Prephase), 2008 (post 1), and 2011 (post 2). Totally, 10 health care units were evaluated, with a minimum of 10 doses evaluated per health care unit, including a minimum of 5 parental doses and a total of 100 nurses observed.
A total of 142 nurses were observed in the prephase, 140 nurses in the post 1 phase, and 98 in the post 2 phase (90% regular staff and 10% float staff). The overall compliance rates went from 77% in 2007 up to 87% in 2008 and down to 78% in 2011.
This cross-sectional observational study revealed a significant difference in the drug use process compliance in terms of drug preparation and drug administration for inpatients at the bedside, between 2007 and 2011.