Journal of Pharmacy Practice

Background: Statins are a highly effective lipid-lowering therapy associated with significant reductions in atherosclerotic cardiovascular disease (ASCVD) events and death. Despite these benefits, statins are underutilized. Pharmacist-led interventions to increase statin prescribing are effective. To our knowledge, no prior studies implemented a comprehensive cardiovascular risk assessment utilizing point-of-care (POC) testing in community pharmacies. Objectives: The primary objective was to determine if community pharmacists can be utilized to identify gaps in care regarding appropriate use of statin therapy for prevention of ASCVD events in HPSAs. Secondary objectives were to assess public interest in ASCVD risk assessment and statin prescribing by the pharmacist, and to identify factors associated with statin gaps in care. Methods: A cross-sectional study was conducted at three independent community pharmacies. Participants were identified based on age and medication history and were scheduled at their pharmacy to receive a comprehensive ASCVD risk screening consisting of POC measurement of a complete lipid panel, blood glucose or A1C, and blood pressure. Participants were informed of their statin candidacy at the screening. Participants completed a survey regarding perceptions of the services provided and opinions of statin prescribing by pharmacists. Results: Of the 57 participants, 43 (75.4%) were possible statin candidates. Most indicated trusting their pharmacist to prescribe a cholesterol-lowering medication and felt insurance should pay for these screenings. Conclusion: ASCVD risk assessment conducted within the community pharmacy setting can be utilized to identify treatment gaps in statin use. Participants indicated trusting pharmacists to provide this service and found the service valuable.

Background: The 2019 Center for Disease Control and Prevention’s Core Elements of Hospital Antibiotic Stewardship identifies community-acquired pneumonia (CAP) as a crucial area for improving antibiotic use. Transitions of care (TOC) pharmacists can optimize medication therapy for CAP patients. Methods: This was a retrospective, multi-hospital analysis of discharge antibiotic prescribing. Between December 1, 2022, and June 30, 2023, TOC pharmacists intervened to decrease discharge days of therapy (DOT) for CAP therapy. The study compared records of CAP patients with a TOC antibiotic stewardship intervention vs those without. An additional three-group analysis compared patients without an intervention to those with an accepted intervention to those with a rejected intervention. Results: 196 patient records were included in the analysis; 80 had a TOC pharmacist intervention and 116 did not. 62 interventions were accepted and 18 were rejected. Mean final discharge DOT was 3.8 ± 1.7 days in the non-intervention group and 3.4 ± 1.6 days in the intervention group (P = 0.231). Mean total DOT was 6.8 ± 2.3 days and 6.8 ± 1.8 days, respectively (P = 0.963). The percentage of patients with appropriate total DOT was 59.5% and 66.3%, respectively (P = 0.337). In the three-group analysis, mean final discharge DOT was 2.9 ± 1.7 days in the accepted group and 4.2 ± 0.9 days in the rejected group (P = 0.030). Mean total DOT was 6.4 ± 1.6 days and 8.1 ± 1.8 days, respectively (P = 0.009). The percentage of patients with appropriate total DOT was 82.3% and 11.1%, respectively (P < 0.001). Conclusion: The accepted TOC pharmacist interventions significantly reduced both discharge DOT and total DOT. These findings emphasize the impact TOC pharmacists can have with antimicrobial stewardship initiatives.

Introduction: With the increasing adoption of alternative payment models (APM) in the U.S. healthcare system there is a growing interest in measuring pharmacy performance with a focus on preventive care and chronic disease management. The Community Pharmacy Enhanced Services Network (CPESN) has been established throughout the U.S. to incorporate high-performing pharmacies to provide enhanced services for high-risk patients including those with diabetes. Methods: The primary objective of this study is to assess the readiness of community pharmacists within CPESN to deliver minimum enhanced services (MES) and diabetes self-management education and support (DSMES) among diabetes patients. A cross-sectional survey was distributed via email to all pharmacies within CPESN New York. Descriptive statistics were utilized to assess survey responses. Results: A total of 84 participants responded to the survey. Top DSMES services offered included: education on blood glucose monitoring (95%), education on lifestyle changes (88%), and monitoring medication adherence to diabetes-related medications (88%). The most time spent per week on DSMES services was for monitoring medication adherence to diabetes-related medications (5.9 +/− 7.0 hours). Top facilitators included technology to execute workflow (55%), adequate workflow design (54%), and proper training for pharmacy personnel (53%). Common barriers in executing services are lack of collaboration with other health professionals (54%) and proper training of pharmacy personnel (49%). Conclusion: CPESN-NY pharmacies demonstrate the opportunity to adapt clinical services including DSMES, which will enhance their performance measures in APMs. Facilitators and barriers have been identified thus next steps in the would be to address how to overcome these barriers.

Background: Evidence supports the safe administration of levetiracetam as a rapid intravenous push (IVP) in patients experiencing breakthrough seizures or status epilepticus. Use of this route of administration may decrease morbidity and mortality by reducing time to medication delivery. Though this practice has become increasingly common in adults, the safety of IVP levetiracetam in pediatric patients is not well documented. Objective: To evaluate the safety of IVP levetiracetam in pediatric patients. Methods: Patients who received IV piggyback (IVPB) or IVP levetiracetam and were between the ages of 12 months and 18 years old were eligible for inclusion. Medication regimen data recorded includes the dose of levetiracetam, number of doses administered, and total days of administration. Additionally, time points related to order entry, pharmacist verification, and dose administration was recorded. Safety endpoints included rates of bradycardia, hypotension, behavioral changes, and cutaneous drug reactions. Descriptive and inferential statistical analysis was performed using SPSS software. Results: This study showed IVP levetiracetam has a similar rate of adverse effects when compared to IVPB levetiracetam in patients over the age of one (5.5% vs 7.5%, P = 0.3589). In addition, there was improvement in the time to administration of levetiracetam (50 min in the IVPB group and 23 min in the IVP group [P = .0008]). Conclusion: Pediatric patients who received undiluted (100 mg/mL) levetiracetam IVP over 5 min had a similar adverse event incidence when compared to those who received the anti-epileptic drug (AED) as an IVPB. This evaluation demonstrated that doses up to 1500 mg of undiluted IVP levetiracetam is safe for pediatric patients.

Tardive dyskinesia (TD) is a syndrome that causes chronic, involuntary, and disruptive movements of the body and/or face that is a severe, potentially irreversible adverse effect of long-term antipsychotic use. It has wide-reaching effects on patients’ well-being, quality of life, ¹ and treatment adherence. ² Thus, TD is debilitating, leading to social withdrawal, ³ and workplace absenteeism. ¹ Current data on tardive dyskinesia treatment are limited, and prevention, primarily through the modification of antipsychotic regimens, remains the most effective strategy. ⁴ Recent systematic review has shown valbenazine and vitamin E are the only treatments significantly more effective compared to placebo in treatment of TD, although valbenazine is associated with significant side effects. ⁵ We present a case of a 76-year-old female with a diagnosis of Bipolar II Disorder (BD) who developed TD after treatment with lurasidone for 10 years. After struggling with both her BD and TD symptoms for 3 years, she sought care at our clinic where we prescribed 300 mg daily of lithium. At her follow-up visit 5 weeks later, her TD symptoms were greatly improved, with sustained benefits observed at following visits. This article reviews the literature discussing the interplay between lithium and TD and presents a case report of TD improvement after lithium augmentation for treatment-resistant depression. While this case suggests a potential role in TD treatment, the role of lithium in TD treatment remains controversial.

Introduction: Roux-en-Y gastric bypass (RYGB) is a surgical weight-loss procedure that combines gastric restriction with malabsorption for weight reduction. There is currently a paucity of data to guide pharmacists and healthcare providers in optimizing oral medication therapy in patients with a history of bariatric surgery. Fluconazole is a commonly used triazole antifungal with high oral bioavailability. The literature is limited regarding how RYGB affects oral fluconazole absorption. Case: We investigated fluconazole oral bioavailability in a patient with a history of RYGB status-post revision with esophagojejunal anastomosis. The patient had been maintained on combination therapy with intravenous (IV) micafungin and oral fluconazole due to persistent candidemia prior to source control and concerns regarding fluconazole absorption. On admission, the patient was switched to IV fluconazole in the setting of possible small bowel obstruction. Steady-state fluconazole trough levels obtained during IV and oral therapy were 41.9 μg/mL and 44.4 μg/mL, respectively. Conclusion: We were able to demonstrate oral fluconazole maintains high bioavailability in a patient with RYGB. Fluconazole displays linear pharmacokinetics, therefore the degree of oral absorption reduction would directly correspond to a decreased trough level. Pharmacists and providers should continue to be vigilant when evaluating drug efficacy in patients who have undergone gastric bypass procedures, especially those with malabsorptive mechanisms.

Background: Over-the-counter topical nasal decongestants are effective and well-tolerated treatments for the temporary relief of nasal congestion, a symptom that can impair quality of life. Their duration of use is limited owing to potential for rhinitis medicamentosa (RM) or rebound congestion (RC), despite uncertainties around the clinical occurrence or onset of these phenomena. Objective: To investigate the clinical occurrence and onset of RM, RC or tolerance with topical nasal decongestants to inform evidence-based recommendation practices for pharmacists and ensure patients do not forego potentially beneficial treatments. Methods: A literature search was conducted with ProQuest to identify and synthesize evidence on RM, RC or tolerance with nasal decongestant sprays or drops. A respiratory specialist and community pharmacist provided clinical perspectives. Results: Eighteen articles were assessed, reporting 13 studies with oxymetazoline, five studies with xylometazoline. There was no evidence of RM or RC after 7 days with oxymetazoline (up to 400 μg total daily dose) or up to 10-days with xylometazoline (840 μg total daily dose). Well-designed studies suggested no occurrence of RM, RC or tolerance with up to 4 weeks of oxymetazoline. No studies evaluating naphazoline, phenylephrine or ephedrine were identified. Conclusion: Oxymetazoline and xylometazoline are highly effective at rapidly improving nasal congestion and have well-established safety profiles. Well-designed studies yielded no evidence of RM, RC or tolerance when used short-term at commonly recommended dosing and frequency. Since some patients may exceed the duration of use in the label, pharmacists can play a vital role in counseling patients on proper intranasal decongestant use and treatment duration.

A blocked or stuffy nose is a common symptom of hayfever and colds that can make daily activities and sleeping difficult. Over-the-counter nasal decongestant sprays or drops work within a few minutes to ease a blocked nose and provide symptom relief. Some studies from around 30 years ago suggested that, when these medicines were used regularly for weeks or months, they might cause a condition called rhinitis medicamentosa, also known as rebound congestion (RC). This is where the lining of the nose swells leading to the nose feeling blocked when the medicines are stopped. We looked for other studies that investigated this effect to see when it might occur and if people developed tolerance to the medicines, meaning they needed to take more for them to work. We included information to help pharmacists treat patients with RC. We found 18 studies that looked at medicines containing xylometazoline or oxymetazoline. When people used these medicines for 7 days (oxymetazoline) or up to 10 days (xylometazoline) there was no evidence of RC. Some well-designed studies found no evidence for RC or tolerance with up to 4-weeks of oxymetazoline use. No studies were found for other medicines in nasal decongestants. When people use xylometazoline- or oxymetazoline-containing medicines as described in the patient information leaflet there is no evidence for RC or tolerance. Pharmacists can play an important role in making sure that patients know how to use the medicines properly, at the correct dose and for no longer than stated in the instructions.

Video Abstract

Please click on the image to play the video (also available as supplemental material). Concerned about rebound congestion from nasal sprays? Review suggests no robust evidence for rebound with oxymetazoline or xylometazoline when used as directed.