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.

Pioglitazone after Ischemic Stroke or Transient Ischemic Attack

Ischemic stroke or transient ischemic attack (TIA) patients are at increased risk for future cardiovascular events. Interestingly, the identification of insulin resistance has been discovered as a risk factor for stroke and myocardial infarction. The resistance of insulin as a risk factor raised the possibility that pioglitazone might benefit patients with cerebrovascular disease. Pioglitazone, which is normally used in patients with Diabetes, improves insulin sensitivity; therefore, Pioglitazone could possibly help with the insulin resistance associated with cardiovascular complications.

In this article, the authors focused on a particular study using the treatment of pioglitazone in patients who had a recent ischemic stroke or TIA. It was a multi center, double-blind trial using 3876 randomly assigned patients. The patients were either treated with pioglitazone (target dose of 45 mg daily) or a placebo. There were 1939 patients in the pioglitazone group and 1937 in the placebo group. The patients involved in the study were not diagnosed with Diabetes, but were found to have insulin resistance based on the HOMA-IR, or homeostasis model assessment of insulin resistance, index.

After 1 year, the HOMA-IR index was lower in the pioglitazone group than in the placebo group. The results after 4.8 years of this study are as follows: A primary outcome (stroke or myocardial infarction) had occurred in 9.0% of the pioglitazone group and in 11.8% of the placebo group. Diabetes developed in 3.8% of the pioglitazone group as compared to 7.7% of the placebo group. Also, pioglitazone was associated with a higher frequency of weight gain (52.2%), edema (35.6%), and bone fracture requiring surgery or hospitalization (5.1%).

In conclusion, the risk of stroke or myocardial infarction was lower among patients who received pioglitazone than among those who received the placebo. Pioglitazone was also associated with a lower risk of diabetes, but with a higher risk of some of the side effects, such as weight gain, edema, and fracture.

 

http://www.nejm.org/doi/full/10.1056/NEJMoa1506930#t=article

Kernan, Walter N., Viscoli, Catherine M., Furie, Karen L., et al. Pioglitazone after Ischemic Stroke or Transient Ischemic Attack. N Engl J Med. 2016.

New front opens in battle against stroke – Medicinal approach cuts recurrence risk by 24 percent in stroke patients

Medical scientists discovered that an already-known drug showed to reduce the risk of stroke or heart attack by almost a quarter in patients who had previously suffered a stroke or mini-stroke!  The drug is pioglitazone, which some of you know is used to treat diabetes.  Pioglitazone works by making the body less insulin resistant, and researchers found that insulin resistance puts you at a risk for heart attack and stroke.

The typical drugs to treat stroke are blood thinners and anticoagulants.  Statins and blood pressure medications may also help in some cases.  It is unusual for a diabetes drug to be used to treat heart attack or stroke.

Blood thinners, statins, and blood pressure management medications have all been shown to significantly reduce the risk for stroke.  However, researchers wanted to explore another risk factor:  insulin resistance, also called “pre diabetes.”

Researchers showed that insulin resistance was associated with a higher risk of stroke and heart attack.  Therefore, they tested pioglitazone, a diabetes drug that can help reduce insulin resistance.

The results of the five-year, double-blind trial of pioglitazone versus a placebo, was that the team found that patients receiving the drug had 24% fewer incidents of either stroke or heart attack.  This is important because pioglitazone may now be used to prevent diabetes as well as heart attack / stroke.

My question is:  Knowing the side effects of pioglitazone, would you been willing to reccommend this medication as a preventative measure? For example, if the patient has a family history of heart attack / stroke, but has not had one?  Do you think the side effects outweigh the benefit of taking the drug as a preventative measure?

 

 

Walter N. Kernan, Catherine M. Viscoli, Karen L. Furie, Lawrence H. Young, Silvio E. Inzucchi, Mark Gorman, Peter D. Guarino, Anne M. Lovejoy, Peter N. Peduzzi, Robin Conwit, Lawrence M. Brass, Gregory G. Schwartz, Harold P. Adams, Leo Berger, Antonio Carolei, Wayne Clark, Bruce Coull, Gary A. Ford, Dawn Kleindorfer, John R. O’Leary, Mark W. Parsons, Peter Ringleb, Souvik Sen, J. David Spence, David Tanne, David Wang, Toni R. Winder. Pioglitazone after Ischemic Stroke or Transient Ischemic Attack. New England Journal of Medicine, 2016; 160217112012002 DOI: 10.1056/NEJMoa1506930

Risks and Benefits Associated with Prestroke Antiplatelet Therapy Among Patients with Acute Ischemic Stroke Treated with Intravenous Tissue Plasminogen Activator

Many patients who present at a hospital with a stroke are already on blood thinners for one reason or another. It is known that intravenous tissue plasminogen activator (tPA) improves the outcomes of ischemic strokes, but the issue is that it also carries the risk for symptomatic intracranial hemorrhage (sICH), which is actually the worst complications that could come from acute ischemic stroke. Another factor is that the blood thinners that these patients are often taking before they have a stroke, which could increase the chances of sICH when the patient is given tPA. The study done by Xian and colleagues aimed to determine if there was a significant increase risk for patients on antiplatelet therapy who received tPA, evaluated the safety of this in groups who would be clinically relevant and investigate the association that exists between being on antiplatelets prior to tPA administration with clinical outcomes in these cases.

This study included patients who had acute ischemic stroke, received intravenous tPA without combination with endovascular treatment, and had been on an anticoagulant regime before the ischemic stroke. The patients were then broken down into groups based on the types of anticoagulant regimes they had been receiving. The endpoints that the study focused on included sICH, in hospital mortality, discharge ambulatory status and the modified Rankin Scale score that ranges from 0 (no symptoms) to 6 (death). Secondary endpoints included were life-threatening or serious systemic hemorrhage within 36 hours, any tPA complication within 36 hours, and discharge destination (home, hospice, inpatient rehabilitation facility, or skilled nursing facility).

The results of this study were interesting because they determined that patients taking anticoagulant therapy did have a higher risk for sICH if they were on anticoagulants just prior to the stroke when given tPA at the hospital. Despite this finding, patients who received tPA did not have higher in-hospital mortality and had better functional outcomes in terms of ambulatory status and mRS scores. This leaves the real judgement up to the health care professionals involved in different individual cases.

It is interesting when a study seems to come up with results that could lead health care professionals in two different directions.What factors could go into making the decision to use tPA or not when a patient presents with an acute ischemic stroke?

Xian Y, Federspiel JJ, Grau-Sepulveda M, et al. Risks and benefits associated with prestroke antiplatelet therapy among patients with acute ischemic stroke treated with intravenous tissue plasminogen activator. JAMA Neurol. 2016;73:50-59)

Primary prevention with lipid lowering drugs and long term risk of vascular events in older people: population based cohort study

The objective of this study was to determine if the use of statins or fibrates in an older population with no history of cardiovascular events affected the risk of coronary heart disease and stroke. The study used a random sample of 7484 individuals(63% female) aged 65 or older from three french cities.

The study found that those using either drug were at a decreased risk of stroke compared to those not using a lipid lowering drug, however no association was found between those using either drug and a decreased risk of coronary heart disease. The researchers analyzed the data based on age, sex, body mass index, and hypertension amongst other variables, and found that overall there was a 30% decrease in risk of stroke for those using a lipid lowering drug.

I think this study is important for understanding the use of statins and fibrates. With the data from this study, there appears to be a clear indication for the use of statins or fibrates for stroke prevention, however there doesn’t seem to be an indication for the use of either drug in prevention of coronary artery disease. With this knowledge, we can help prevent drug therapy problems and recommend that different drugs should be used to prevent coronary heart disease.

Link to study

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.