Journal of Pharmacy Practice

Many states have pharmacist contraceptive prescribing laws with several others in the process of enacting similar legislation. Little continuity or standardization exists across these programs, including development of counseling materials. Although the risk of unplanned pregnancy is greatest among adolescents and young adults, developed materials are not always sensitive to youth.

To use a modified Delphi method to develop standardized youth-friendly counseling tools that are sensitive to pharmacy workflow during pharmacist contraceptive prescribing.

A multidisciplinary expert panel of women’s health pharmacists, community pharmacists, adolescent medicine pediatricians, obstetrician–gynecologists, and public health advocates was assembled and reviewed materials over 3 iterations. Comments were anonymized, summarized, and addressed with each iteration. A graphic designer assisted with visual representation of panel suggestions. Reviewer feedback was qualitatively analyzed for emergent themes.

The Delphi method produced 5 main themes of feedback integrated into the final materials including attention to work flow, visual appeal, digestible medical information, universal use of materials, and incorporating new evidence-based best practices. Final materials were scored at a Flesch-Kincaid grade of 5.1 for readability.

The use of the Delphi method allowed for the efficient production of materials that are medically accurate, patient-centered, and reflect multiple disciplinary perspectives. Final materials were more robust and sensitive to the unique needs of youth.

Anticoagulants are among the most frequently prescribed medications in the United States. Racial and ethnic disparities in incidence and outcomes of thrombotic disorders are well-documented, but differences in response to anticoagulation are incompletely understood.

The objective of this review is to describe the impact of race and ethnicity on surrogate and clinical end points related to anticoagulation and discuss racial or ethnic considerations for prescribing anticoagulants.

A PubMed and MEDLINE search of clinical trials published between 1950 and May 2018 was conducted using search terms related to anticoagulation, specific anticoagulant drugs, race, and ethnicity. References of identified studies were also reviewed. English-language human studies on safety or efficacy of anticoagulants reporting data for different races or ethnicities were eligible for inclusion.

Seventeen relevant studies were identified. The majority of major trials reviewed for inclusion either did not include representative populations or did not report on the racial breakdown of participants. Racial differences in pharmacokinetics, dosing requirements, drug response, and/or safety end points were identified for unfractionated heparin, enoxaparin, argatroban, warfarin, rivaroxaban, and edoxaban.

Race appears to influence drug concentrations, dosing, or safety for some but not all direct oral anticoagulants. This information should be considered when selecting anticoagulant therapy for nonwhite individuals.

Nonadherence to medications is a concern due to adverse outcomes and higher costs of care. The Centers for Medicare and Medicaid Services has made adherence a key measurement for Star ratings.

To evaluate the impact of a collaborative pilot program between a third-party payer, local pharmacy organization, and academic institution focusing on improving medication adherence with community pharmacies.

Twenty-five community pharmacies implemented adherence-based interventions in patients ≥65 years old, who were Medicare Advantage Plan members, taking targeted medications (statins, oral diabetic medications, angiotensin-converting enzyme inhibitors [ACE-Is] and angiotensin receptor blockers [ARBs]). Outcome measures were (1) pharmacy intervention completion rate, (2) type of adherence interventions, (3) change in the proportion of days covered (PDC) following pharmacist intervention based on adherence group, and (4) nonadherence barriers.

A total of 1263 interventions met the eligibility criteria, and common interventions included explaining the benefit of the medication (n = 453, 35.9%) and provider follow-up (n = 109, 8.6%). Among nonadherent subjects who became adherent, the mean PDC increased by 14% (74%-88%, P < .0001), with a 12% decrease in mean PDC score in the nonadherent who remained nonadherent group (71%-58%, P < .0001). Common patient barriers for nonadherence were forgetfulness (n = 451, 35.7%) and denial (n = 84, 6.7%). System and therapeutic barriers included complexity (n = 155, 12.3%) and adverse side effects (n = 42, 3.3%).

This collaborative effort successfully implemented a community pharmacist-led adherence intervention in 25 independent pharmacies. Our findings highlight increased interactions with patients and in some cases improved adherence measures. Future research must include implementation outcomes in order to effectively implement these interventions in the community pharmacy setting.

Antibiotics are commonly prescribed for uncomplicated urinary tract infection (UTI) and acute otitis media (AOM) and may be unnecessary at times. The aim of this study was to evaluate prescribing practices for UTIs and AOM in a rural ambulatory care setting and to identify areas for improvement.

In a single-center, retrospective review conducted at a rural clinic, patients diagnosed with uncomplicated UTI and AOM were included. Patients were identified by International Classification of Diseases, Tenth (ICD-10) codes, and data were collected for visits between January 1, 2017, and December 31, 2017. The primary outcome was to assess adherence of antimicrobial prescribing to current treatment guidelines.

Of the 76 patients identified, 28 met inclusion criteria. Of the 28 patients, 75% received an agent recommended first line in the treatment guidelines, and 18 of the 21 received a recommended dose. Only 17% of patients were prescribed an appropriate duration of treatment.

Opportunities exist for antimicrobial stewardship interventions for uncomplicated UTIs and AOM. Prescribers are not consistently adhering to guidelines in regard to antibiotic choice, dose, or duration. Additional education and stewardship interventions are crucial considering the increased prevalence of antimicrobial resistance.

Venous thromboembolism (VTE) is the second leading cause of death in patients with malignancy. The currently available guidelines have shown greater support for utilization of low-molecular-weight heparin (LMWH) over direct oral anticoagulants (DOACs) in cancer-associated VTE. Current data on the safety and efficacy of DOAC therapy in patients with cancer are lacking.

To evaluate the safety and efficacy of the use of DOACs compared to LMWH in patients with cancer.

A retrospective review of outpatient records was completed to identify patients with documented cancer diagnosis and either a DOAC or LMWH as a listed medication. Patients were excluded if they had atrial fibrillation, valvular disease, antiphospholipid antibody syndrome, current pregnancy, body mass index (BMI) >40 kg/m² or weight >120 kg, severe renal or hepatic impairment, or were on concomitant therapy with a significant interacting medication. The primary outcome was frequency of VTE recurrence, and secondary outcomes included the frequency of major and minor bleeding and other thrombotic events.

One hundred fifty-six patients were included in the study population, 78 in both the DOAC and LMWH groups. Venous thromboembolism recurrence occurred in 5 (6.4%) patients in the DOAC group and 8 (10.3%) patients in the LMWH group (P = .39). There was no significant difference in major or minor bleeding or other thrombotic events between the 2 groups.

The frequency of VTE recurrence was similar between DOACs and LMWH in patients with cancer. DOACs may be an alternative agent to LMWH for the prevention of recurrent VTE in patients with cancer.

Studies have shown an association between metformin use and vitamin B₁₂ deficiency. Since 2017, the American Diabetes Association (ADA) Standards of Medical Care in Diabetes Guideline has included a recommendation for periodic vitamin B₁₂ measurements in metformin-treated patients, especially those with anemia or peripheral neuropathy.

To determine the overall incidence and impact of the ADA Guideline on vitamin B₁₂ monitoring in a veteran population on long-term metformin therapy.

Retrospective chart review was performed for patients on metformin who started therapy prior to 2005 at the VA North Texas Health Care System (VANTXHCS). The primary outcome was the proportion of patients with at least 1 vitamin B₁₂ level drawn during 2016 versus 2018. Metformin dose and duration, vitamin B₁₂ supplementation, and incident neuropathy prescriptions or diagnosis were also analyzed.

Of 394 patients included for the primary outcome, 136 (34.5%) had at least 1 vitamin B₁₂ level in 2016 versus 198 (50.3%) patients in 2018 (odds ratio: 1.94, P < .001). Of the 394 patients, 157 were diagnosed with neuropathy or prescribed a medication for neuropathy without a vitamin B₁₂ level in the previous year or with a low level that was not supplemented.

Vitamin B₁₂ monitoring significantly increased between 2016 and 2018, aligning with the release of the 2017 ADA guidelines. However, a large proportion of patients were identified who were diagnosed with or treated for neuropathy without adequate vitamin B₁₂ monitoring.

After publication of the Clostridioides difficile infection (CDI) guidelines by the Infectious Disease Society of America (IDSA) in early 2018, we identified that many prescribers at our institution continued to practice using the older guidelines.

This study aimed to determine whether the implementation of an electronic order set for CDI would increase prescriber compliance to current IDSA recommendations for CDI management.

This was a single-center, prospective cohort study of adult inpatients with a confirmed CDI. The study was conducted between March 1, 2018, and April 1, 2019. Patients were stratified into a preintervention and postintervention group before and after order set implementation. The primary outcome was a composite of appropriate CDI therapy selection and discontinuation of nonessential antimicrobials and acid-suppressive agents. The secondary outcome evaluated appropriate CDI therapy medications prescribed at hospital discharge.

Of the 149 patients included in this study, 96 were included in a preintervention group and 53 included in a postintervention group. The primary outcome was met in 45% of patients in the preintervention group and 66% of patients in the postintervention group (P = .01). The secondary outcome occurred in 86% of patients in the preintervention group and 100% of patients in the postintervention group (P = .02).

Implementation of a CDI electronic order set and alert bundle was associated with enhanced prescriber adherence to guideline-directed therapy. Our results suggest that order sets not only improve inpatient compliance to guidelines but may also improve medication-related adherence to guideline recommendations upon discharge.

(1)To compare Part D plan switching for users and nonusers of a pharmacy-led Medicare Part D consultation service and (2) to evaluate the effect of service use on chronic medication adherence.

This was a longitudinal study, occurring in one independently owned community pharmacy in Iowa. Medicare Part D beneficiaries who used the service were compared to nonusers. Dispensing data were used to compare planswitching and the effect of service use on chronic medication adherence between service users and nonusers. Proportion of days covered (PDC) was used to evaluate medication adherence.

In the 2017 and 2018 plan year, 79 and 138 Medicare beneficiaries used the service, respectively. These individuals were compared to 849 Medicare beneficiaries and a random sample of 101 beneficiaries in respective years. The respective switching rates for service users in 2018 and 2019 plan year were 43% and 15.9%, compared to 4% switching rates in both years for nonusers. Using the Medicare Part D consultation yielded a statistically significant positive effect on switching in both plan years (P values < .05) and a statistically significant positive effect on PDC between years (P value <.05).

The use of a pharmacist-led Medicare Part D consultation resulted in increased plan switching and improved chronic medication adherence.

To determine the willingness to discuss and be screened for pre-exposure prophylaxis (PrEP) in pharmacies among MSM.

Led by Georgia’s Fulton County Board of Health, this study surveyed individuals who attended 2 Atlanta-based Gay Pride events in 2018. This analysis was limited to those who identified as men who have sex with men (MSM) who were not HIV positive and reported never using PrEP. Multivariable regression was used to determine the correlates of willingness to discuss and be screened for PrEP in-pharmacy.

Most (69%) were willing to discuss PrEP with pharmacy staff and 61.35% were willing to be screened for PrEP in-pharmacy. Those who were interested in PrEP were significantly more willing to discuss PrEP in-pharmacy compared to those not interested in PrEP (prevalence ratio [PR]: 1.65; 95% confidence interval [95% CI]: 1.11-2.48). Race was not associated with willingness to discuss PrEP with pharmacy staff. However, black MSM (BMSM) were less willing to be screened in pharmacies than white MSM, until we accounted for interest in PrEP (PR: 1.27; 95% CI: 1.09-1.48).

Pharmacies may be an optimal setting to expand PrEP access to reach racial minorities who have the highest need but are not being reached. Pharmacy-based PrEP discussions and screening could improve awareness of HIV status and increase PrEP knowledge and uptake. Future studies should determine optimal pharmacy conditions under which PrEP screening and uptake are acceptable for BMSM.

Current literature suggests that patients with psychiatric disorders are at an increased risk for inpatient readmission. This study evaluated the impact of pharmacist-driven discharge medication reconcilliation (DMR) on readmission rates of patients discharged with one or more psychotropic medications.

This study was a retrospective review of patients receiving a pharmacist-driven DMR. The primary outcome was to compare the prevalence of 30-day readmission rates among patients who had a pharmacist DMR between patients who had at least one psychotropic medication upon discharge versus those without psychotropic medications. Secondary objectives were to (1) compare the number of medication discrepancies and pharmacist interventions prior to discharge and (2) compare prevalence of medical comorbidities between patients who had at least one psychotropic medication upon discharge versus those without psychotropic medications.

A total of 151 subjects were included who had a DMR and either at least one psychotropic medication at discharge (n = 69) or no psychotropic medications at discharge (n = 82). The 30-day readmission rates were similar between both groups (P = .609). The mean number of discrepancies (P < .001) and number of pharmacist interventions (P = .005) were significantly greater in patients who had at least one psychotropic medication upon discharge compared to those without psychotropic medication.

The prevalence of 30-day readmissions was similar between the two groups; however, patients discharged with at least one psychotropic medication had a greater number of discrepancies requiring significantly more discharge interventions during a pharmacist DMR.

Few would argue that emergency department utilization volumes do not tax the health system. Currently, there is not a process defined by Centers for Medicare and Medicaid Services for transitioning this patient population back to their primary physicians following emergency department visits. Resource limitations in a rural family medicine setting create barriers to dedicate focus on this important transitional care management from urgent care visits to primary care office.

To describe a novel pilot process for transitional care management from the emergency department utilizing pharmacy student extenders to overcome resource limitation at a rural family medicine clinic and establish follow-up primary physician contact.

From a master list provided, student pharmacists proactively telephoned patients and reviewed medication changes while assisting with scheduling follow-up appointments at the patient’s primary physician clinic.

The result of these efforts increased the communication with patients and resulted in a 26% (10/38) increase in follow-up appointments scheduled with a total increase of an additional 7 patients adhering to follow-up transitional appointment.

This approach utilizing student extenders is a feasible and sustainable process that can increase patient contact when resources are limited, while serving as an educational tool for next generation providers.

Per the Centers for Medicare and Medicaid Services (CMS) Code of Federal Regulations (CFR) 482.23(c) regarding medication administration, hospital policies and procedures must identify time-critical scheduled medications which must be administered within 30 minutes either before or after the scheduled dosing time, for a total administration window of 1 hour.

The general objective of this analysis was to determine whether there was a difference in meeting medication administration goals when comparing time-critical to non-time-critical scheduled medication administration in both intensive care units (ICUs) and general medical floors at a large, academic medical center.

Data were collected in 6 inpatient nursing units (3 general medical units and 3 ICUs) during the month of June 2017. Electronic medical record charge data for medications were used to evaluate timeliness of medication administration.

In total, 69,794 medication administrations were evaluated. Of 389 administrations of time-critical scheduled medications, 268 (69%) were administered on time. Of 69,405 administrations of non-time-critical scheduled medications, 58,099 (84%) were administered on time (P < 0.001). ICUs had a higher percentage of on-time administrations than general medical units (89% vs 77%, P < 0.001), and nurses had a higher percentage of on-time administrations than respiratory therapists (84% vs 63%, P < 0.001).

Non-time-critical scheduled medications were more commonly administered on time compared with time-critical scheduled medications. Staff education and optimizations to the electronic health record (EHR) are interventions that may improve administration of time-critical scheduled medications.

In cases of oral factor Xa (FXa) inhibitor–associated acute major bleeding, several reversal strategies are available. Current guidelines recommend a dose of 50 U/kg if using 4-factor prothrombin complex concentrate (4F-PCC). A paucity of data exists with the use of 4F-PCC for FXa inhibitor reversal for acute major bleeding, specifically the most efficacious dosing regimens and safety data. The purpose of this case series is to describe the utilization of 4F-PCC for reversal of oral FXa inhibitor–associated acute major bleeding.

This retrospective case series included all admitted patients 18 years and older who received 4F-PCC for oral FXa inhibitor–associated major bleeding. Major bleeding was defined using the International Society of Thrombosis and Hemostasis definition for major bleeding in nonsurgical patients. The primary outcome was achievement of hemostasis.

A total of 31 patients met inclusion criteria, with 17 receiving rivaroxaban and 14 receiving apixaban. Intracranial hemorrhage was the most common type of bleeding occurring in 15 (55%) patients. The median dose of 4F-PCC was 37 U/kg. Of the patients evaluated in the primary end point analysis, 68% achieved effective hemostasis. Four (12.9%) patients experienced a documented thrombotic event within 7 days of receiving 4F-PCC.

The use of 4F-PCC for FXa inhibitor–associated acute major bleeding was effective for the majority of patients. The rate of thrombotic events appears higher compared to previously published studies, although major confounders exist and larger studies are needed to fully evaluate the safety of 4F-PCC for this indication.

To evaluate the benefits of postgraduate year 1 (PGY1) pharmacy residency program expansion on clinical outcomes, pharmacy services, educational outreach, costs, and preceptor time at a community teaching hospital.

During academic years 2014 to 2016, two PGY1 resident positions existed, expanding to four PGY1 resident positions during 2016 to 2018. Quantitative analyses comparing the aforementioned periods evaluated clinical interventions, adverse drug events prevented, community and hospital educational programs provided, departmental costs, and documented preceptor hours as a result of program growth. The outcomes were assessed using descriptive statistics.

The mean number of documented clinical interventions completed by the resident classes with two residents was 2906 when compared to 5324 with four residents. The mean number of prevented adverse drug events was 56 during the years with two residents and 220 in the years with four residents. The number of community outreach programs increased from 2 to 18 per year. The number of resident lectures provided to allied health professionals increased from 11 to 16 sessions per year. The net economic impact associated with two residents in 2014 was +$4661 USD, while in 2017 the net impact was −$5262 USD. The mean preceptor hours spent per year related to residency activities with two residents was 1005 hours compared to 1109.5 hours with four residents.

Through strategic modification, expansion of the PGY1 residency program led to increased documentation of clinical interventions, prevented adverse drug events, and educational programs provided with minimal change in preceptor burden.

Guidelines have differing recommendations for aspirin use in patients with an indication for anticoagulation. The purpose of this study was to evaluate the incidence of major bleeding and thromboembolic events (TEs) in patients with atrial fibrillation (AF) receiving warfarin alone (monotherapy group) versus warfarin plus aspirin (combination therapy group).

This was a retrospective, cohort study including patients from a pharmacist-run anticoagulation clinic. Inclusion criteria were patients with AF receiving anticoagulation between January 2013 and January 2014 observed over 5 years.

One hundred forty-two patients were included in the combination group versus 89 in monotherapy group. In the combination group, 60 (42.3%) patients were on aspirin for no apparent indication, 19 (13.4%) had stable coronary artery disease and diabetes, and 26 (18.3%) had diabetes alone. Major bleeding occurred in 21 (14.9%) patients in the combination group versus 7 (7.9%) patients in the monotherapy group (odds ratio [OR] = 2.02, 95% confidence interval [CI]: 0.78-5.91; P = .17). TE occurred in 10 (7%) patients in the combination group versus 4 (4.5%) in the monotherapy group (OR = 1.61, 95% CI: 0.44-7.24; P = .57). There was no significant difference in bleeding (P = .85) or TE (P = .37) rates between aspirin indications in the combination group.

Combination therapy versus monotherapy may increase bleeding risk with little benefit in decreasing AF-related stroke or cardiovascular events.

To compare opioid prescribing behavior of emergency medicine providers following the enactment of Connecticut Public Act (PA) 15-198 at a large academic tertiary medical center.

This study is a single-center pre and postlaw retrospective cohort of ED patients discharged with opioid prescriptions. Patients discharged from January 1, 2015, to June 30, 2015, were analyzed as the prelaw cohort, and patients discharged from January 1, 2016, to June 30, 2016, were analyzed as the postlaw cohort. The primary outcome was the cumulative dose of solid dosage forms of opioids per prescription, calculated in morphine milligram equivalents (MME).

A total of 10,307 prescriptions included in the final analysis. A statistically significant decrease in the primary outcome was seen in the postlaw cohort compared with the prelaw cohort, respectively (75 MME [interquartile range, IQR: 60-100) vs 80 MME [IQR: 75-150]; P < .001). The postlaw cohort also saw 1289 (22.2%) fewer opioid prescriptions, primarily driven by a reduction in the number of schedule II opioids prescribed. In a posthoc analysis, the primary outcome remained statistically significant even when opioid prescriptions were only included if their prebuilt settings were unchanged between pre and postlaw cohorts, respectively (85.1%; 95.6 MME (±56.0); n = 5041 vs 86.7 MME (±39.6); n = 3713; P < .001).

The passage of PA 15-198 was associated with a decrease in the cumulative dose of opioids per prescription of solid dosage form products. This drop was precipitated by a transition from using opioids in schedule II to opioids in schedule IV and a modest decrease in prescribed opioid quantity.

Limited data are available that examine hospital readmission outcomes of sliding scale compared to basal-bolus insulin in indigent and insulin-naive patients.

To evaluate hospital readmission outcomes in patients who are insulin naive with type 2 diabetes mellitus who are initiated on either sliding scale or basal-bolus insulin upon hospital discharge.

A retrospective chart review was conducted of adult patients with a history of type 2 diabetes mellitus, who were insulin naive, had a hemoglobin A_1c (HbA_1c) 10% or greater, and were discharged with a prescription for sliding scale or basal-bolus insulin from January 2015 to July 2018. The primary objective measured all-cause 30-day hospital readmissions. The secondary objectives measured diabetes-related 30-day hospital readmissions and HbA_1c change after 3 months of initial hospital admission. Data were analyzed using descriptive statistics, χ² test, paired sample t test, and logistic regression.

Forty-one patients were prescribed sliding scale insulin and 105 patients were prescribed basal-bolus insulin. The majority were male (60%), spoke English (84%), were self-pay (39%), and had a mean age of 51 ± 10.2 years, initial HbA_1c of 13% ± 1.9%, and LACE+ score of 51 ± 15.6 upon discharge. All-cause 30-day hospital readmissions occurred in 14.6% of sliding scale and 6.7% of basal-bolus insulin groups (odds ratio [OR]: 2.40, 95% confidence interval [CI]: 0.75-7.63). Hyperglycemia occurred in 7.3% of sliding scale and 0.9% of basal-bolus insulin groups. Mean HbA_1c difference for basal-bolus and sliding scale insulin was 3.3 ± 3.1 and 2.9 ± 2.7, respectively (P = 0.459).

There was no significant difference in all-cause 30-day hospital readmissions comparing sliding scale to basal-bolus insulin.

The purpose of this article is to review the currently available assessment tools for measuring renal function, body weight, and body surface area in the amputee population.

PubMed and Web of Science were searched using the following key terms: amputation, dose adjustment, and estimation of body weight. Articles published in languages other than English were excluded from the search.

Despite the increasing prevalence of amputations, there is little literature available that discusses its impact on the patient and how these physiological changes can affect pharmacokinetics. Very little information is available to guide dose adjustment in this patient population. This article discusses several factors to consider when determining optimum dosing regimens in patients with different levels of amputations.

This article will evaluate the applicability of methods mentioned in existing literature for measuring changes in renal function, body weight, and body surface area in amputees.

To provide a summary of the most prominent peer-reviewed infectious diseases (ID) pharmacotherapy and Human Immunodeficiency Virus (HIV)-related articles published in 2019.

Houston Infectious Diseases Network (HIDN) members were asked to nominate articles that they believed were most influential within the ID and HIV pharmacotherapy science communities. A total of 48 general ID and 6 HIV-related articles were nominated. Following nominations, an online survey was distributed via e-mail to Society of Infectious Diseases Pharmacists (SIDP) members, with a total of 156 and 54 members voting for general ID and HIV-related articles, respectively. The results of this survey were ranked to determine the top 10 general ID and top HIV articles. The top articles were then summarized by HIDN members, including residents, fellows, and clinical pharmacists.

This review covers many of the most influential ID articles published in 2019, including 3 practice guideline updates. Due to the high rate of ID literature published each year, this review continues to help summarize these articles for the ID community, allowing clinicians to remain up-to-date on practice-changing publications in ID and HIV pharmacotherapy.

Amantadine is commonly used to treat Parkinson’s disease. A case of myoclonus and asterixis was associated with amantadine is reported.

An 80-year-old man with Parkinson’s disease diagnosed in 2015 was started on amantadine for treatment of progressive tremor and orofacial dyskinesias induced by levodopa. He took amantadine 100mg orally daily for 7 days, then increased to 100mg twice a day thereafter. The patient complained of “worsening tremor” after 9 days and amantadine was decreased to 100mg daily. After 1 month on this dose, the patient reported that his “tremor” persisted and experienced visual hallucinations. His examination demonstrated diffuse myoclonus throughout his extremities and trunk, as well as asterixis when attempting to stand or holding his arms antigravity. Laboratory testing for renal and hepatic failure was unrevealing. Amantadine was reduced to 50mg daily for 4 days and then discontinued. Myoclonus resolved 3 days after discontinuation of amantadine.

While amantadine-induced myoclonus is rare, health care providers should be vigilant in monitoring for signs and symptoms of myoclonus following amantadine initiation.