Identification of risk factors associated with acute kidney injury in patients taking sodium-glucose cotransporter-2 inhibitors.

STUDY OBJECTIVE: Studies have demonstrated sodium-glucose cotransporter-2 (SGLT2) inhibitors are kidney protective; however, their ability to cause hemodynamic changes may predispose patients to acute kidney injury (AKI). An FDA warning recommends evaluating for factors that predispose patients to AKI before initiating a SGLT2 inhibitor. The primary objective of this study is to identify risk factors that may predispose persons with diabetes to AKI when initiating SGLT2 inhibitor therapy. DESIGN: Multicenter retrospective cohort chart review. DATA SOURCE: Study patients were identified through an electronic medical record generated report if they had type 2 diabetes and were prescribed a SGLT2 inhibitor from January 2013 to September 2019. PATIENTS: Patients were included if they were receiving care at Advocate Medical Group and were confirmed to have taken one of the four SGLT2 inhibitors available at the time of study approval, canagliflozin, dapagliflozin, empagliflozin, or ertugliflozin, for at least 7 days. Patients were excluded if they did not have a basic metabolic panel or comprehensive metabolic panel recorded 1 year prior to or 6 months after SGLT2 inhibitor therapy initiation. RESULTS: Data extraction from the electronic medical record identified 6425 patients receiving a SGLT2 inhibitor, of which 1962 met inclusion criteria and were included for analysis. Thirty-five (1.8%) patients experienced an AKI after SGLT2 inhibitor therapy initiation. There was no statistically significant difference between groups based on background medication use (p = 0.325). At baseline, patients experiencing an AKI after SGLT2 inhibitor initiation were more likely to be older in age (p = 0.010), have a higher serum potassium (p < 0.001), blood glucose (p = 0.018), SCr (p = 0.009) and UACR (p < 0.001), and a lower eGFR (p = 0.028) compared to those who did not experience AKI. CONCLUSIONS: The transient eGFR decline with SGLT2 inhibitor initiation should be expected and is generally not an indication to discontinue therapy. Future initiatives should be directed at increasing knowledge of monitoring recommendations for these agents.

Cultivating best practices in care transitions through comprehensive medication management.

An estimated 20% of patients experience a postdischarge adverse event in the 30 days after hospital discharge, with approximately two-thirds of these events considered preventable or ameliorable. Numerous transitional care interventions have been developed and implemented by clinical pharmacists to reduce postdischarge adverse drug events and readmissions; however, most efforts are focused on the admission and discharge process. Low-quality evidence and mixed results from evaluations of postdischarge interventions have left health care organizations unsure which interventions provide the greatest value and how to optimize their implementation. Comprehensive medication management (CMM) is an approach, usually delivered by a pharmacist in collaboration with the health care team, which aims to standardize the wide variability in medication-specific pharmacist-led services to optimize medication use and improve clinical outcomes. This article aims to discuss how CMM can be used to cultivate best practices in care transitions.

Deprescribing in type 2 diabetes and cardiovascular disease: Recommendations for safe and effective initiation of glucagon-like peptide-1 receptor agonists in patients on insulin therapy.

Select glucagon-like peptide-1 (GLP-1) receptor agonists have demonstrated cardiovascular benefits in both primary and secondary prevention populations and are recommended in multiple guidelines for cardiovascular risk reduction in people with type 2 diabetes (T2D). Despite this, uptake of GLP-1 receptor agonists in clinical practice has been lagging. While the etiology of their underuse is multifactorial, lack of comfortability in adding a GLP-1 receptor agonist to established insulin regimens is a common barrier. Adjustments to basal and bolus insulin doses upon initiation of GLP-1 receptor agonists in trials have varied. When recommending empiric dose adjustments during initiation of GLP-1 receptors agonists, the most recent A1C and the current blood glucose levels, if available, should be taken into consideration. When initiating in a person being managed with basal-only insulin regimens, an empiric 20 % dose reduction is recommended if the baseline A1C is ≤8 %. For individuals using intensive insulin regimens, empiric dose reductions of up to 25 % in basal and 50 % in bolus therapy were implemented and summarized further in this review. Overall, initiation of GLP-1 receptor agonists can decrease insulin requirements and may permit deintensification of antihyperglycemic therapy through the reduction or discontinuation of bolus insulin therapy. As a result, this simplified regimen promotes increased adherence, reduces glycemic variability and hypoglycemia, and improves overall glycemic management and quality of life. This review aims to serve as a guide for clinicians to facilitate the initiation of GLP-1 receptor agonists and deintensification of insulin by providing suggested dose adjustments based on available literature.

Personal Formularies of Primary Care Physicians Across 4 Health Care Systems.

Importance: More conservative prescribing has the potential to reduce adverse drug events and patient harm and cost; however, no method exists defining the extent to which individual clinicians prescribe conservatively. One potential domain is prescribing a more limited number of drugs. Personal formularies-defined as the number and mix of unique, newly initiated drugs prescribed by a physician-may enable comparisons among clinicians, practices, and institutions. Objectives: To develop a method of defining primary care physicians' personal formularies and examine how they differ among primary care physicians at 4 institutions; evaluate associations between personal formularies and patient, physician, and practice site characteristics; and empirically derive and examine the variability of the top 200 core drugs prescribed at the 4 sites. Design, Setting, and Participants: This retrospective cohort study was conducted at 4 US health care systems among 4655 internal and family medicine physicians and 4 930 707 patients who had at least 1 visit to these physicians between January 1, 2017, and December 31, 2018. Exposures: Personal formulary size was defined as the number of unique, newly initiated drugs. Main Outcomes and Measures: Personal formulary size and drugs used, physician and patient characteristics, core drugs, and analysis of selected drug classes. Results: The study population included 4655 primary care physicians (2274 women [48.9%]; mean [SD] age, 48.5 [4.4] years) and 4 930 707 patients (16.5% women; mean [SD] age, 51.9 [8.3] years). There were 41 378 903 outpatient prescriptions written, of which 9 496 766 (23.0%) were new starts. Institution median personal formulary size ranged from 150 (interquartile range, 82.0-212.0) to 296 (interquartile range, 230.0-347.0) drugs. In multivariable modeling, personal formulary size was significantly associated with panel size (total number of unique patients with face-to-face encounters during the study period; 1.2 medications per 100 patients), physician's total number of encounters (5.7 drugs per 10% increase), and physician's sex (-6.2 drugs per 100 patients for female physicians). There were 1527 unique, newly prescribed drugs across the 4 sites. Fewer than half the drugs (626 [41.0%]) were used at every site. Physicians' prescribing of drugs from a pooled core list varied from 0% to 100% of their prescriptions. Conclusions and Relevance: Personal formularies, measured at the level of individual physicians and institutions, reveal variability in size and mix of drugs. Similarly, defining a list of commonly prescribed core drugs in primary care revealed interphysician and interinstitutional differences. Personal formularies and core medication lists enable comparisons and may identify outliers and opportunities for safer and more appropriate prescribing.

Advocating for the pharmacy profession through involvement in a type 1 diabetes day camp as a pharmacy residency learning experience.

OBJECTIVE: Diabetes summer camps have the common objectives of providing children with diabetes a safe environment to have fun and develop skills to manage diabetes in the presence of variable physical activity and nutritional intake. Historically, the American Diabetes Association (ADA) has relied on nurses, dietitians, and physicians to serve as medical staff, whereas pharmacists served in educational roles. This commentary describes the experience of postgraduate year-2 (PGY-2) ambulatory care pharmacy residents participating as medical staff in the management of children with type 1 diabetes (T1D) at a week-long, summer day camp in an elective learning experience. DESCRIPTION: Two PGY-2 residents volunteered at ADA-sponsored camps in July and August 2017, in which they were responsible for performing and documenting blood glucose measurements, dosing and administering insulin, overseeing the use of insulin pumps and continuous glucose monitors, and managing cases of hypo- and hyperglycemias in children aged 4-9 years. They facilitated interprofessional education of other medical staff members, including discussions regarding pharmacokinetic profiles and formulations of various insulin products and performing advanced insulin dosing adjustments. SUMMARY: The perceived benefits of this residency learning experience included increased self-confidence regarding the management of T1D, insulin administration techniques, and interprofessional collaboration. Performing advanced clinical management of children with T1D increased awareness of pharmacists' skill set in diabetes care. Demonstrating this value in nontraditional care settings may increase the likelihood that pharmacists are recruited to interdisciplinary health care teams to participate in autonomous direct patient care. CONCLUSION: The PGY-2 ambulatory care pharmacy residents autonomously practiced as recognized medical staff in the management of pediatric patients with T1D. This experience advocates for pharmacists' and their trainees' involvement in service-learning and team-based medical care outside the traditional health care setting.