Pharmacists’ role in a hospital’s initiative to become a certified primary stroke center

Pharmacists played a critical role in helping a hospital to earn their designation as a certified primary stroke center. A certified primary stroke center, or a “PSC” is a certification designated by the dual efforts of the American Heart Association and American Stroke Association. A PSC certification for a hospital means better care for stroke patients, and can increase patient confidence in the hospital and recruit more talented healthcare professionals. In 2010, New Hanover Regional Medical Center (NHRMC) in North Carolina saw the opportunity to improve their stroke care and gain their certification and help treat more patients in an area that has higher rates of stroke mortality than any other region in America. In order to gain this certification, they made a “Code Stroke” multidisciplinary response team that included the pharmacy director and created a position for a direct patient care pharmacist. The Code Stroke team reviewed outcomes data and oversaw the creation and operations of stroke procedures. This included streamlining the care of stroke patients, from admission to discharge.

A critical element of this streamlined process was the role of the pharmacist. Pharmacists were assigned to the emergency department, ICU, progressive care unit, and outpatient pharmacy that serves to discharged patients. All the different pharmacy units used the same computerized-prescriber-order-entry system, that allowed for consultations, monitoring, chart reviews, and notification about discharges. This integration between the pharmacists was aimed at reducing dosing errors, preventing incorrect administration of alteplase, and decreasing the amount of time it takes to administer alteplase to a stroke patient. Since there is an emergency room pharmacist, they can be one of the first healthcare professionals to correctly assess the medication needed for the patient. Also, the program instituted a 24-hour emergency department pharmacist, makes sure that all pharmacists on emergency department rotations are up to date on Code Stroke duties. Ultimately, NHRMC did obtain the certification, thanks largely in part to the pharmacy unit. I think that this article shows the importance of pharmacists in clinical settings, and how pharmacists across different units of a hospital can improve care when there is adequate communication and transitions of care. By reducing medication errors and improving patient outcomes, I think that the role of the pharmacist in clinical settings will only continue to increase.

 

Link: http://www.ajhp.org/content/73/5_Supplement_1/S1.long

 

 

Reference: Gilmer A, Sweeney L, and Nakajia S. Pharmacists’ role in a hospital’s initiative to become a certified primary stroke center. Am J Health Syst Pharm. 2016. 73 (Supplement 1):S1-S7.

Stopping vs. Continuing Aspirin before Coronary Artery Surgery

Many patients who are at risk for MI and stroke will be on an aspirin therapy. However, when these patients are undergoing surgery aspirin poses an increased bleeding risk during surgery. The normal practice is to have patients stop their aspirin regimen 5 to 7 days before surgery. However, the beneficial results of aspirin could outweigh the bleeding risk during surgery. This study examined whether an aspirin regimen should be stopped before coronary artery surgery.

The study enrolled patients who were going to have coronary artery surgery, and were at an increased risk for complications due to age or other comorbidities. Patients were then randomized, and if on warfarin therapy had to stop 7 days before surgery. Patients were randomly assigned evenly to receive 100 mg aspirin or a placebo. Data on patients risk scores were recorded, and then twelve-lead electrocardiography was preformed before the surgery, and one, two, and tree days post-operation, and at discharge. Blood samples were obtained 12 to 24 and 48 to 72 hours after surgery to measure troponin or CK-MB. Patients were also contacted 30 days after surgery. Outcomes measured were death and negative cardiac events. There were 1047 patients in the aspirin group and 1054 patients in the placebo group. Within the 30 days after surgery the amount of deaths or thrombotic complications in the two groups was 202 patients (19.3%) in the aspirin group, and 215 patients (20.4%) in the placebo group. Myocardial infarction within the first 30 days was 144 patients in the aspirin group (13.8%) and 166 patients (15.8%) in the placebo group.

Ultimately, this study found that these results were not significant enough to indicate that preoperative aspirin resulted in more health risks due to increased bleeding during coronary artery surgery. It further supported the idea that withdrawal of aspirin regimens pre-op could potentially harm patients. However, there are a lot of areas in this study that still need to be further examined in order to find more definitive recommendations. For example, the study used a low dose of aspirin (100 mg), and patients could be resistant to the antiplatelet effect of aspirin. Hopefully there will be more studies performed that examine aspirin use pre coronary artery surgery, in order to more appropriately dose patients and provide more successful patient outcomes.

 

 

Link: http://www.nejm.org/doi/full/10.1056/NEJMoa1507688#t=articleDiscussion

 

Citation:

 

Myles, PS, Smith JA, Forbes A, et al. Stopping vs. Continuing Aspirin before Coronary Artery Surgery. N Eng J Med. 2016; 374:728-737.

Increase in Naloxone Prescriptions Dispensed in US Retail Pharmacies Since 2013

Overdoses from heroin and prescription opioids are a public health crisis in America. One way to reduce the amount of overdoses is to administer naloxone, an opioid antagonist, to those who are likely to witness an opioid overdose. Naloxone was traditionally given out through community programs that would give overdoes educations. Recently there has been a focus on increasing naloxone access through prescribing naloxone in outpatient settings. While there has been data showing the efficacy of naloxone and reducing opioid overdoses in community program settings, this study aimed to analyze the prescription trends of naloxone.

Prescription data was obtained through IMS Health’s National Prescription Audit. The time period observed was from July 2010 and June 2015, and was divided into 3 groups: Evzio, an auto-injector form that was approved in 2014, the 2mg/2mL formulation normally used off label with nasal atomizer, and other formulations. The study found that Naloxone dispensed from retail pharmacis was low and stable from 2010 to 2013, ranging between 241 and 463 prescriptions per quarter. Until June 2015, there was a sharp increase in dispensing, and a 1170% increase since the fourth quarter of 2013. This was mirrored by a 187% increase in the number of naloxone kits given by community programs, and a 160% increase in the number of opioid overdose reversals reported by community programs.

This study shows that prescription of naloxone can aid the efforts of community programs. While community programs distributes the most naloxone, the public health crisis of opioid overdose needs more methods of administering naloxone, and prescriptions for naloxone can help aid this effort. However, there is still more work that needs to be done. This includes examining the barriers patients may face obtaining naloxone, opioid prescribing trends, and any stigma patients may face. Overall, I think that this shows the impact that pharmacist can have in a community pharmacy setting and how we can aid in a public health crisis. By being aware of the impact we can make on an at-risk population, we can try to be conscious of the stigma this population may face and try combat this.

 

 

Reference: Jones CM, Lurie PG, and Compton WM. Increase in Naloxone Prescriptions Dispensed in US Retail Pharmacies Since 2013. Am J Public Health. doi:10.2105/AJPH.2016.303062 (published 18 February 2016).

 

Link: http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2016.303062?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub%3Dpubmed&

Phenytoin for neuroprotection in patients with acute optic neuritis: a randomised, placebo-controlled, phase 2 trial

Acute demyelinating optic neuritis is one of the most common symptoms of multiple sclerosis. Since multiple sclerosis is a demyelinating disorder in the CNS, this can also manifest in the eye. Patients will experience a loss of color vision, burry vision, and orbital pain. This occurs through neurodegeneration of the optic nerve and retina fibers. There is growing evidence that in acute relapses of neurodegeneration, there is a cascade from neuronal energy failure, and part of that cascade is inhibition of the sodium potassium ATPase, and sodium ions will accumulate. Voltage-gated sodium channel inhibitors have been found in other clinical studies to be neuroprotective, giving reason to believe they would be neuroprotective in multiple sclerosis.

This study looked at whether phenytoin (a selective sodium-channel inhibitor) is neuroprotective in patients with optic neuritis. The study performed was a randomized, parallel-group, double-blind, and placebo-controlled phase 2 trial. Patients were between ages 18-60, had a clinical diagnosis of unilateral acute demyelinating optic neuritis, and an interval of less than 14 days between vision loss and randomization. They were then randomized and assigned evenly to a phenytoin (n = 39) or placebo group (n = 42). Those in the phenytoin group either received 4 mg/kg dose or 6 mg/kg To measure the efficacy, high resolution spectral domain OCT images, and low-contrast letter scores to assess vision, and MRIs were obtained at the beginning of the study and after 6 months. The mean difference after 6 months in the affected eye phenytoin group was 0.20mm3 ( p = 0.005), a 34% reduction of macular volume lost compared to the placebo. Overall, this study found that phenytoin made a significant reduction in loss of retinal nerve fiber layer thickness and volume compared to the placebo. However, there were no significant differences in symptomatic visual outcomes. Treatment with phenytoin was well tolerated in the patients. The findings from this study support larger phase 3 trials to further examine use of phenytoin in acute demyelinating optic neutitis, and other neurodegenerating disorders.

I thought this study was interesting because it was examining the approval of a marketed drug for new indications. Right now phenytoin is commonly used in epileptic patients to prevent seizures, so a new indication for MS patients at first seems strange. However, as studies learn about new mechanisms and systems present in different organs we can see how previously approved drugs can also have therapeutic outcomes in different organ systems. With the astronomic costs to approve new drugs, and high rates of the drugs never going to market, a lot more studies are being performed to examine novel uses for approved drugs. I wonder if these would be safer for patients, considering that these drugs have been on the market longer and (presumably) more adverse effects would be known, or whether this is an ineffective approach.

 

 

 

 

Link: http://www.thelancet.com/pdfs/journals/laneur/PIIS1474-4422(16)00004-1.pdf

 

Citation:

Raftopoulos R, Hickman SJ, Toosy A, et al. Phenytoin for neuroprotection in patients with acute optic neuritis: a randomised, placebo-controlled, phase 2 trial.

Lancet Neurol. 2016; 15: 259–69.

Generic-to-generic lamotrigine switches in people with epilepsy: the randomised controlled EQUIGEN trial

Switching between generic medications can often be a difficult decision or transition for the patient, as there are many concerns about less effective medications or new side effects. This study looked at the effect of switching between two generic lamotrigine immediate-release drugs in patients who have epilepsy.

This was a double-blind, randomized, crossover study that recruited adult patients already taking generic immediate-release lamotrigine twice daily at either 100mg, 200 mg, 300 mg, or 400 mg. Patients in the study were then randomly assigned a treatment sequence (1 or 2). The study was then divided into two 14-day portions. For the first 14 days of the study they would continue to receive the doses they were on before the study. After 14 days, the patients were changed to the other generic product. This study aimed to measure the bioequivalence of the different generic drugs, so at the end maximum plasma concentration and AUC for the generic forms were analyzed.

The study found that the maximum plasma concentrations and AUC were within equivalence limits, and that the exposures were equivalent between the different generic forms. No significant side effects were reported by the patients, and there were no changes in clinical lab values or vital signs during the study.

I found this study fascinating because I thought it dealt with how the perception of a drug can really effect it’s use. Even though the FDA has approved interchanging generic anti-epilepsy medications, there is still this perception among both physicians and patients that you’re putting the patient at risk for potentially increased toxicity or decreased efficacy. I think that this showed how research studies can not only bring novel uses or innovations to the medical field, but also sometimes serve to reassure practitioners about safe practices.

 

 

Link: http://www.thelancet.com/journals/laneur/article/PIIS1474-4422(16)00014-4/abstract

 

Citation:

Privitera, M., Welty, T., Gidal, B., Diaz, F., Krebill, R., & Szaflarski, J. et al. (2016). Generic-to-generic lamotrigine switches in people with epilepsy: the randomised controlled EQUIGEN trial. The Lancet Neurology. http://dx.doi.org/10.1016/s1474-4422(16)00014-4

Impact of a medication therapy management intervention targeting medications associated with falling: Results of a pilot study

The use of fall risk increasing drugs (FRIDs) in older adults can be one of the major precipitators for falls in older adults. Older adults can both be prescribed FRIDs and be taking OTC FRID medications. This pilot study was conducted by using MTMs with patients and their community pharmacists in order to reduce the number of falls patients experienced and reduce the amount of FRIDs older adults were using. Participants in the study were English speaking, older than 65, and had fallen in the last year. Ultimately 79 adults participated in the trial. The adults were recruited after completing a fall prevention workshop, and participation was voluntary. Trained student pharmacist first contacted the participants via phone to complete a one hour pre-intervention survey. Then, the pharmacist conducted a one hour long targeted medication therapy review with the participants. The pharmacist then made a medication action plan for the participant that included modifications to FRID use, and discussed the MAP with the patient. If needed, the pharmacist would also contact prescribers with the recommendations. Participants received 5 monthly, 30 minute follow-up calls from student pharmacists acquiring information about how many falls they had experienced and whether they started any new medications.

Of the 79 adults participating in the trial, 38 were randomly assigned to the intervention group and 41 were assigned to the control groups. 33% of the intervention group and 44% of the control group subjects were using at least one FRID. A significantly (P < 0.05) larger proportion of subjects in the intervention group stopped using all FRIDs (76.9%) than the control group (27.8%). It was found that the most common medication related problem for FRID were OTC sleeping medications. 56% of recommendations were for OTC products, and 89% of those recommendations were communicated directly to the patient. Also, this study did not show a significant difference in the amount of falls before and after the pharmacist intervention.

Ultimately, this pilot study showed that pharmacist interventions have a significant effect in reducing the amount of FRIDs used for elderly patients. The MTM reviews also utilized motivational interviewing, and this study highlighted the importance of participant involvement, since those who originally signed up for the fall prevention seminar did so on their own accord. I think that this study shows the importance of community pharmacist in recognizing improper FRID use in older adults, and helping those patients to modify their prescription or OTC medication to reduce the risk of falls.

 

Link: http://www.japha.org/article/S1544-3191(15)00002-3/abstract

 

Citation: Impact of a medication therapy management intervention targeting medications associated with falling: Results of a pilot study

Mott, David A. et al.

Journal of the American Pharmacists Association , Volume 56 , Issue 1 , 22 – 28

Evaluation of cost versus antioxidant determinants in green tea dietary supplements

This study examined green tea supplements and whether their cost was indicative of their overall quality. Quality was measured by their chemical composition and their antioxidant activity. Green tea and it’s advertised antioxidants are a very popular herbal supplement within healthcare. It contains catechins which are linked to the treatment of reducing lipid parameters and coronary artery disease. As such, many pharmacists are often asked by their for a recommendation on which green tea supplements are best. Since most patients would assume that the more expensive products are of higher quality, this study examined whether or not that was true.

The study was conducted by purchasing 26 different green tea supplements, then measuring the total phenolic content, total antioxidant capacity, and antioxidant activity in each. Percentage of these components where then compared to cost per unit. This study found a number of interesting outcomes. First, supplements advertised as single, double, or triple strength did not actually contain the amount of antioxidant activity the label described. Furthermore this study found that the bioavailability is 5 to 50 times less in vivo compared to in vitro, suggesting that the higher strength products should be purchased for a noticeable effect. Interestingly, the study did not find a correlation between higher price and higher antioxidant activity, and recommended buying the highest advertised strength, regardless of price. Last the study found that green tea bags often have the least antioxidant activity, with multiherb formulation having the highest antioxidant activity.

I was really interested in this article because for our Innovative Practices presentation in POP1, Dr. Cosgriff from the Portland VA hospital discussed with us how he had to perform a lot of literature reviews on herbal supplements that his patients bring into the pharmacy. While learning about pharmacy, I think I have the tendency to forget that herbal remedies will be something I will be seeing coming into the pharmacy and that I’ll need to be a trusted source of advisement on whether my patients can use them and if they have any adverse drug reactions. However, this article also made me think about determining the cost/value ration of herbal supplements and what to recommend for my patients. I thought that this study was really looking out in the patient’s best interest, and provided helpful insight into a market that is not as strictly regulated as prescription drugs.

 

 

Link: http://japha.org/article.aspx?articleID=2336797

 

Citation: 

Roberson CLA, Abourashed EA, Elsharkawy N. Evaluation of cost versus antioxidant determinants in green tea dietary supplements. J Am Pharm Assoc. 2015;55:381-389.

Pharmacists Help Encourage Short Term Antibiotic Regimines

This study aimed to reduce the duration of antibiotics prescribed to children with uncomplicated skin and skin structure infections. Uncomplicated skin and skin structure infections, or uSSTIs, usually are treated with antibiotic therapy and include simple abscesses, cellulitis, impetiginous lesions, and furuncles. Complicated skin structure and skin structure infections (cSSTIs) affect deeper skin or are considered complicated in an immune-deficient patient. These include major abscesses, infected burns and ulcers, other infected wounds, and diabetic foot infections. The guidelines from Infectious Diseases Society of America for the management of SSTIS suggest a 5 day course of antibiotic treatment for uSSTIs, and can be extended if improvement is not made. The short antibiotic courses can help prevent antibiotic resistant bacteria from forming, lower costs, and reduce adverse effects. This study took place at the Cincinnati Children’s Hospital Medical Center, and aimed to increase short course antibiotic treatment (less than 7 days) in patients who came in with uSSTIs, compared to the previously used long-course therapy which lasts 7 to 14 days. At the beginning of this study 23% of patients with uSSTIs were prescribed short course antibiotic treatment.

To accomplish the study’s goal, they used a few methods. First, they had two 15-minute information sessions with residents and attendants. They also attached information cards about optimal antibiotic regimens for SSTIs to medical personnel’s identification badges. Pharmacists identified the third intervention as part of a multidisciplinary team, who noted that the order set default for uSSTIs was a 14-day course of therapy. The last intervention method was having a team member from the study contacting the physicians attending to SSTI patients and reiterating that short term antibiotic therapies can be used for uSSTIs, and to contact them with any questions. 5 months after the project began, 74% of patients with uSSTIs were discharged with the short term antibiotic therapies, and there was no significant difference in the amount of readmissions or recurrence for those who received the short term antibiotic treatment.

I really thought that this article showed the importance of pharmacists as part of a healthcare team, and how pharmacists can contribute innovative practices to medication changes. While changing the automatic duration of therapy in the prescribing system may seem simple, it can remind and alert the physician about the benefits of short term antibiotics and lead to less human error and increased savings. Also, this was the first time I had heard about short-term antibiotic regimens. While at first it seemed a little strange to me since I’ve been taught a lot about the importance of finishing antibiotic treatments to avoid resistance, it makes sense that shorter term antibiotic regimens would lead to increased patient adherence. Do you think that any of these methods could be implemented into a community pharmacy setting? Could pharmacists have played a more important role in this study, perhaps by educating pharmacists as well so that they can perform interventions when filling out prescriptions?

 

Citation: Schuler CL, Courter JD, Conneely SE, et al. Decreasing Duration of Antibiotic Prescribing for Uncomplicated Skin and Soft Tissue Infections. Pediatrics. doi: 10.1542/peds.2015-1223 (published 18 January 2016).

 

Link: http://pediatrics.aappublications.org/content/early/2016/01/15/peds.2015-1223