Sublingual tacrolimus as an alternative to oral administration for solid organ transplant recipients

In this article, researched looked at available data to analyze sublingual tacrolimus and provide recommendations for solid organ transplant recipients.  Tacrolimus is an anti-rejection (immunosuppressant) medication that is available in many dosage forms but sublingual was analyzed in this study.

Typically, oral tacrolimus is used to prevent organ transplant rejection but due to it’s nature in a clinical setting many different situations occur that may prevent oral delivery.  For this reason, the researches wanted to explore the efficacy of a sublingual dosage form. The study found that about 50% of the oral dose needed to be delivered sublingually in order to get the targeted therapeutic effect.

Overall, the study helped to solidify the idea that sublingual dosing could be used as a short-term therapy for patient who cannot receive oral delivery.

Do you think that more drugs should be available sublingually? Especially ones used in a clinical setting?

Pennington CA, Jeong MP. Sublingual tacrolimus as an alternative to oral administration for solid organ transplant recipients.  Am J Health Syst Pharm.  2015;72(4):277-84.

Computerized Decision Support Improves Medication Review Effectiveness: An Experiment Evaluating the STRIP Assistant’s Usability

When physicians prescribe medications to patients with certain disease states, there is no way of determining whether the medication that is being prescribed will work for the patient. For example, obtaining adequate control of chronic disease states may involve a process of testing different medications on a patient until one can be deemed as an appropriate treatment option. There are different programs that have been established in the past to provide aid to physicians looking to initiate therapy options on a patient; however, they have not been proven to cause changes in care that lead to clinically significant improvement. For this reason, a new tool referred to as STRIP (Systemic Tool to Reduce Inappropriate prescribing) has been developed to optimize the prescribing process by conducting medication reviews in the primary care setting. This program is a computer-based technology that allows physicians to analyze patients medication histories and preferences to determine the best form of therapy.

In this study, 42 physicians were asked to optimize medical records of patients utilizing multiple medications by both the traditional manner and by the STRIP analysis. Utilization of the STRIP assistance program was linked to an increase in the number of appropriate medication decisions (to 76% from 58% without). Along with this, physicians on average spent more time meeting with patients and discussing treatment options using the program. The only major negative result gathered from the study was the fact that it received a below-average score by physicians examining the usability of the system. Therefore, the STRIP assistance program was determined to be an effective tool for providing medication reviews.

I believe this study is important because it shows how one of the main roles of a pharmacist (providing medication reviews) benefits the overall experience that a patient will have with their medication. I believe having systems like this in place to aid physicians in the process of decision making will allow pharmacists to eventually become more active in the process of prescribing medications. This is something that I think is important due to the amount of knowledge that pharmacists have about medications. Optimization of prescribing methods will not only benefit the health of the individual receiving the medication, but it will also ensure that we are limiting the cost that adverse effects from drugs have on the health care system. I believe that the role of a pharmacist will only continue to expand over the next couple of decades, and as a result, the profession will be more respected by the public.

In-Hospital Outcomes and Costs Among Patients Hospitalized During a Return Visit to the Emergency Department

In this article, researchers explored what types of outcomes patients experience as well as what resources are utilized when patients are hospitalized during a unscheduled return visit to the ED.  The study looked at parameters including in-hospital mortality, ICU admission, length of stay, and inpatient costs.

Unexpectedly, patients who returned to the ED after initially being discharged had a lower in-hospital mortality rate. They also had lower ICU admission rates, lower hospital costs, and longer lengths of stay.  They article attempts to suggest that the idea of readmission as a negative might not tell the whole story.  It may not be as telling about deficits in the quality of care as we previously thought.

The problem that I have with these findings is that the data seems to suggest that patients who are initially admitted to the ED are not receiving a high quality of care.  In both cases, being discharged or returning, something is not going right.  If a patient is leaving the ED, they should be able to rest assure that they were taken care of properly.  They should not worry about having to return when their condition worsens.

One way I believe we could fix this problem is with the use of pharmacists.  In POP we learned about the many mistakes patients make with their medication upon discharge.  Having a pharmacist on staff to explain medications to the patients might help to reduce the number of readmissions.

Sabbatini AK, Kocher KE, Basu A, et al. In-hospital outcomes and costs among patients hospitalized during a return visit to the emergency department. JAMA. 2016;315(7):663-671.

Evaluating the Effects of an Interdisciplinary Practice Model with Pharmacist Collaboration on HIV Patient Co-Morbidities

HIV patients are likely to have certain medical co-morbidities at a higher prevalence than members of their age group and are more vulnerable to adverse events related to these problems. For this reason, monitoring of patients with this condition is highly utilized through primary care clinics that specialize in the treatment of the infection in association with chronic disease states. The disease states common among HIV patients over the age of 60 include hypertension (45% of people), diabetes (21% of people), and vascular disease (23% of people). Interdisciplinary practice models used in treatment of patients with this condition have been effective in managing these chronic disease states. Because pharmacists play a crucial role in how HIV patients adhere to medications and treatment guidelines, this study focused on determining if there is a benefit to adding pharmacists to this inter professional team.

This study found that pharmacists were able to help in the management of  lipid levels and the cessation of smoking. Along with this, pharmacists were found to significantly decrease the amount of money these patients spend management of their individual chronic co-morbidities (with average savings of $3,000). For this reason, pharmacists involvement in the primary care of patients with HIV should expand past the provision of medications to include counseling and other services.

I think this study is important due to the fact that it represents how the role of a pharmacist within the health system is constantly changing. We are not only trusted sources of information for medications and proper treatment techniques, but we are also crucial in providing adequate counseling to patients. This is something that I believe has been a major focus throughout our studies in pharmacy school over the course of the year, and as a result, a feel I will be well prepared to fill this role in my future profession. This article makes me want to learn specific ways that I can help patients from this population manage their condition.

Cope R, Berkowitz L, Arcebido R, et al. Evaluating the effects of an interdisciplinary practice model with pharmacist collaboration on HIV patient co-morbidities. AIDS Patient Care and STDs. 2015, 29(8): 445-453

Antidepressant Use and Risk of Recurrent Stroke: A Population-Based Nested Case-Control Study

Approximately 30% of individuals that have had a stroke are also diagnosed with depression, and although antidepressant therapy is recommended in patients with post-stroke depression, there are no guidelines for choosing therapy options. For this reason, a study was conducted to determine the relationship between the use of various classes of antidepressant medications and the recurrence of stokes. This longitudinal study analyzed health insurance database information of adults over the age of 18 who had a stroke and were readmitted with this condition. Around 10,000 patient cases were included in the study results (6,679 controls; 3,536 cases).  The study found that there was not an increased risk of stroke recurrence in patients taking SSRIs for depression; however, a correlation was found in patients being treated with TCAs (1.41 times increase). The risk for stroke recurrence in patients taking TCAs did not show much differentiation when analyzing dose and treatment duration variations. As a result, the study highly recommends using alternative methods of treatment for depression symptoms in patients who have experienced a stroke.

I believe this article is important to the understanding of pharmaceutical care due to the fact that antidepressants are one of the most commonly prescribed classes of medications. As healthcare professional that prioritize on the safety of treatment methods, we should be aware of medication contraindications so that we can provide the best patient care. Although all healthcare professionals look out for the best interests of the patient, pharmacists specialize on medications and thus will have the best knowledge on the potential dangers associated with treatment methods. This study makes me want to learn more about specific medication contraindications so that I will no how to protect patients health after graduation from pharmacy school.

 

 

Improving Patients Primary Medication Adherence

Pharmacists across the globe face a key issue in their ability to provide patients with the tools that enable them to adhere to medication regimens. Increasing adherence to prescribed treatment options will help to improve the overall health outcomes of the patients that pharmacist’s are serving.  For this reason, research into the causes for non-adherence and its resulting issues is and will continue to be an area of high importance. The interest that I have in improving medication adherence led me to the article entitled improving Patients Primary Medication Adherence.

This article is focused around a study completed in a French hospital during the months of November 2010 to June 2011. The study, which included patients over the age of 18 that were admitted into the ITD (Infectious and Topical Disease) and the general medicine unit, was developed to determine if incorporating clinical pharmacy activities into the discharge process would decrease the amount of post-discharge adverse effects.  To assess the results of this study, medication adherence was determined by contacting the patients’ community pharmacists 7 days after discharge.  The study did not find a correlation between the rate of re-admittance and/or visits to emergency rooms, but patients who received extra counseling during discharge were more likely to be adherent to newly prescribed medications.  For this reason, the study supported the idea that adherence can be increased by providing discharge counseling sessions to patients.

I feel like this is an important study for us to consider as pharmacists because managing patient adherence to medication regimens is the most important role we play in improving health outcomes.  By improving adherence, we have the ability to lower the risk for serious adverse drug events which can lead to hospitalization.  For this reason, I believe that pharmacists should implement all activities that are proven to increase adherence to maximize the results of treatment options.  This article has left me wondering how similar programs to increase medication adherence can be implemented in community pharmacy settings.

Leguelinel-Blache G, Dubois F, Bouvet S, et al. Improving patient’s primary medication adherence: the value of pharmaceutical counseling. Med. 2015;94(41)

 

Neonatal Pharmacist to the Rescue: Caring for the Hospital’s Most Vulnerable Participants

This article discusses a clinical pharmacist, Dr. Keliana O’Mara, who works in the neonatal ICU at the University of Florida Health Shands Hospital. She is the only pharmacist in this unit, and her role there is incredibly important.

One of the sickest patients that O’Mara had to work with was a baby girl who was born at 28 weeks gestation. This baby had a congenital diaphragmatic hernia and cardiac defect. Because her diaphragm did not develop completely, her abdominal contents were pushed into her chest cavity, and as a result she only had the functionality of 1.5 of her lungs.

O’Mara did a significant amount to save this baby’s life while the baby was in the neonatal ICU. She was in charge of the pain and sedation management for the infant as she went in and out of several surgeries for developmental defects. After all of the infant’s surgeries, O’Mara realized that the infant had developed a fungus in her blood. As a pharmacist, she was able to notice that the antifungal that the infant was to be started on would most likely not work because the infant had been on it previously, and the fungus in the infant’s blood was most likely resistant to the medication as a result. O’Mara was able to collaborate with the primary physician and get the medication changed to a broader spectrum antifungal medication. This was beneficial because a later culture showed that the fungus in the infant’s blood would have indeed been resistant to the original medication.

Another role that O’Mara has in the neonatal ICU is to help implement better treatment methods there. For example, by looking at 2 years of vancomycin dosing data, O’Mara realized that half of the infants in the NICU never reached a therapeutic level of this antibiotic in their blood. As a result, she got permission to begin individualized pharmacokinetic/pharmacodynamic dosing for vancomycin. This is when a pharmacist evaluates serial blood concentrations of a drug after patients receive the first dose. The pharmacist then creates an appropriate dosing regiment personalized for each patient based on these values. Doing this for vancomycin ultimately led to a quicker clearance of bacterial infections in infants in this NICU, and therefore a shorter amount of time that they needed to be on the antibiotic.

Pharmacists who work in the neonatal ICU are additionally crucial because of how small the doses are for babies. Pharmacists must make sure that an infant is never getting too much medication and that mixtures of medications are always made properly. Adding more fluid to a dose to dilute it is not possible for a 500 mg infant because this could lead to fluid overload in the baby. As a result, pharmacists working in this unit have to be extra precise and careful. They also need to make sure the team they are working with understands the latest drug data. It is their job to show physicians when a medication should not be used in an infant, for example if scientific data shows that the treatment and placebo yields the same response from a drug.

I overall found this article very interesting. It is incredible how different one’s experience can be as a pharmacist just by working in one unit of a hospital over another. It also is crazy to think how easy and life threatening it can be to mess up one small part of an infant’s medication regimen. It is clear that a pharmacist is crucial in the NICU of every hospital, and it amazes me how much of an impact one pharmacist can have on saving someone’s life and allowing a premature baby to one day make it home.

Pharmacy Today. 2015;Health-System Edition:2-3.

http://pharmacytoday.org.marlin-prod.literatumonline.com/article/S1042-0991(15)30102-X/pdf

 

Utilizing Trainee-Integrated Pharmacy Practice Model to Alleviate DTPs in Cardiology

The role of a pharmacist on an inter-professional health care team and their importance to preventing medication related issues in patients that results in hospital re-admissions has been widely studied and accepted as necessary among pharmacists and providers alike.  Despite this, many hospitals and clinics are unable to free up the personnel to include enough clinical pharmacists on teams due to the large time commitment associated with such a position.  A new study posted in the North Carolina Journal of Medicine attempted to test the feasibility of  a Trainee-Integrated Pharmacy Practice (TIPP) model that would utilize pharmacy residents in a cardiology clinic to perform comprehensive medication services under the supervision of a clinical pharmacist preceptor.

In the pilot study, a clinical pharmacist divided time between three teams comprised of pharmacy residents and technicians in critical, intermediate, and acute care cardiology units.  Each team was responsible for rounding with the existing care team at in the units, and would make care plan recommendations, verify medication orders, counseling on high-risk medications, and medication reconciliation with the guidance of their clinical pharmacist preceptor.  The study tracked the medication recommendations made by each team, as well as the time commitments made by each member of the team to compare the demands that would be place on individual clinical pharmacists.

The results of the study show that after 30 days, the residents and their preceptor managed to find 512 medication reconciliation issues including necessary drugs omitted, incorrect doses, wrong frequencies, duplicate medications, and discontinued medications still being taken.  They also increased the rates of patients receiving anti coagulation counseling by 70%, and recommended 762 clinical changes,an average of about 3.5 per patient, of which 720 were accepted by the care team.  These recommended alterations generally involved medication optimization, over a fourth of which were recognized by literature to improve general health outcomes and adverse cardiovascular events.  Also, the study found that the teams were active in the clinical care process for an average of 10-12 hours per day, with the assistance of medication history compiled by technicians and a staffed medical record specialist to cut down on time spent for patient profiles.  This suggests that the time investment necessary would far exceed one clinical pharmacists ability to provide the same services and speaks to the viability of the integrated trainee team.

 

This study may open doors on inter professional teams for pharmacy residents in patient care roles that currently are not the standard of practice.  The study indicates that utilization of trainee-preceptor teams could alleviate the deficit for pharmacy expertise in the clinical setting that most hospitals do not have the resources for.  Do these teams provide the depth of knowledge required for positive clinical changes, or should hospitals only be entrusting these issues to established clinical pharmacists? How do you feel about this?

Article Link

Reference:

Kalich B, Cicci J, et alFrom Pilot to Practice: A Trainee-Integrated Pharmacy Practice Model in Cardiology. N C Med J. 2016; 77: 45-51. doi:10.18043/ncm.77.1.45