Megesterol acetate as an overlooked cause of hyperglycemia in end-stage renal disease: A case of polypharmacy.

OBJECTIVES: This case report highlights an overlooked cause of hyperglycemia and risk of polypharmacy in a patient with end-stage renal disease (ESRD). CASE SUMMARY: A 75-year-old non-English speaking male with T2DM, hypertension, coronary artery disease status post percutaneous coronary intervention, and ESRD secondary to IgG Kappa nephropathy on nightly peritoneal dialysis reported a loss of appetite, decrease in weight, and an increase in symptoms of depression. As a result of these symptoms, his nephrologist initiated megestrol acetate (MA), an agent commonly used in ESRD to help stimulate appetite and improve weight. After starting MA, his blood glucose (BG) significantly worsened, due to its glucocorticoid properties. Basal insulin was started to manage his hyperglycemia, but there was minimal improvement in BG. As the patient was referred to the endocrinology clinical pharmacist for diabetes management, it was identified that his weight loss began after starting dulaglutide, which led to a weight loss of 11 kg (12.9%). The Naranjo algorithm was used, and he had a score of 6, which is a probable reaction. The patient's endocrinology and nephrology teams agreed to discontinue MA and dulaglutide as they resulted in opposing effects on appetite and BG, as well as insulin glargine. The patient's BG was tightly controlled off MA and his appetite, weight, and mood improved off dulaglutide. PRACTICE IMPLICATIONS: This case report reflects the potential effects of polypharmacy in ESRD, resulting in poor patient outcomes and drug interactions. It is imperative that a comprehensive medication reconciliation is completed on all patients, especially for patients on dialysis. It is also important for healthcare professionals to be cognizant of medications that may exhibit glucocorticoid properties, which can cause hyperglycemia. Including a clinical pharmacist in the care team can assist with medication reconciliation, screening for drug interactions and polypharmacy, and optimizing chronic disease management.

Implementation of a pharmacist-led weight loss service to improve medication access and weight loss.

BACKGROUND: Obesity is a prevalent medical condition that can contribute to an increased risk of developing serious comorbidities, leading to an increase in hospitalizations, morbidity, and mortality. Many of these medical conditions can be improved with weight loss. OBJECTIVES: This project was designed to improve weight loss outcomes and assess the utilization of services provided by clinical pharmacists for collaborative weight loss management. METHODS: The study design was a single-center, retrospective, and quality improvement study within 3 outpatient clinics at Tufts Medical Center. Patients referred to the pharmacist-led weight loss service from September 1 to October 31, 2022, and continued care for up to 6 months were included. Pharmacist services included selection of weight loss medication, assistance with medication access, device teaching and dose titration, lifestyle counseling, and follow-up. The primary outcome was percent weight loss from baseline. RESULTS: Seventy-nine patients were referred to the pharmacist-led weight loss service. Mean age of patients was 51 years (SD ±13). Sixty-one patients were female (77.2%). Median baseline weight was 105.5 kg (IQR 93.1 to 120.5 kg) and body mass index 38.1 kg/m2 (IQR 33.9 to 43.5 kg/m2). The median percent weight loss from baseline through the end of the study duration was -8.0% (IQR -3.1 to -12.1%). CONCLUSION: Pharmacists were able to effectively provide weight loss care through a pharmacist-led weight loss service by aiding in medication access, providing education on devices and lifestyle management, and engaging in frequent follow-up. Future directions of this study include expansion of the pharmacist-led weight loss service to other ambulatory care clinics within TMC.

An Overlooked Medication-Induced Celiac Flare Complicating Treatment of Osteoporosis.

Background/Objective: Celiac disease, an immune reaction to gluten causing nutrient malabsorption, and long-term glucocorticoid therapy adversely affect bone metabolism and increase fracture risk. Case Report: A patient with long-standing celiac disease on a strict gluten-free diet and long-term glucocorticoid therapy status post kidney transplant for Sjögren syndrome-induced interstitial nephritis presented for management of osteoporosis. Initial evaluation was notable for secondary hyperparathyroidism, which resolved after switching to a gluten-free calcium citrate supplement. Given normal serum total alkaline phosphatase (ALP) and parathyroid hormone (PTH), she began treatment of osteoporosis with abaloparatide. Two months later, she reported abrupt onset of diarrhea with significant weight loss. Biochemical investigation revealed a threefold increase in serum ALP level. As a precaution, abaloparatide was suspended, yet symptoms persisted with elevated ALP and PTH levels. Endoscopy revealed a celiac flare. The clinic-based pharmacist found that her pharmacy had inadvertently dispensed prednisone tablets containing wheat starch. A switch to a gluten-free formulation led to rapid resolution of the diarrhea with weight regain. Serum ALP and PTH levels normalized, and abaloparatide was resumed without biochemical abnormalities. Discussion: An unintended switch to a gluten-containing prednisone formulation resulted in uncontrolled celiac disease causing calcium malabsorption, secondary hyperparathyroidism, elevated ALP levels, and an interruption in osteoporosis therapy. Common supplements and drugs can be a hidden source of gluten. Collaboration with a clinic-based pharmacist enhances the detection and prevention of medication-induced adverse reactions. Conclusion: This case highlights the importance of a careful review of gluten-containing medications and supplements in patients with celiac disease.

Assessing HIV Preexposure Prophylaxis Education in a Family Medicine Residency.

BACKGROUND AND OBJECTIVES: HIV preexposure prophylaxis (PrEP) has been purposefully incorporated into our family medicine resident training within existing didactic lectures, readings, and routine office visit precepting. This mixed-methods evaluation assesses training strategies for PrEP use via survey and drug use evaluation (DUE). METHODS: We surveyed 80 current and former family medicine residents (2014-2018) about their exposure to training components, self-reported confidence and competency in PrEP use, and practice behaviors reflecting CDC guidelines for patient eligibility and testing. In addition, we conducted a DUE of patients receiving PrEP from 2012-2018 for adherence to CDC guidelines. We report results with descriptive statistics, with χ2 analysis for group comparisons. RESULTS: Survey response rate was 56.3%. Among respondents, 46.7% have prescribed PrEP and 55.5% self-assessed as competent to prescribe PrEP, with the majority (84%) rating precepting as most effective for building competence. Those self-assessed as competent were more likely to endorse practice behaviors reflecting CDC guidelines for monitoring PrEP (P<.05). DUE identified 68 patients; 98.5% men who have sex with men. No women with recent sexually transmitted infections, nor persons who inject drugs (PWID) received PrEP. Initial testing completion ranged from 79.4% (HIV) to 54.4% (hepatitis B). Follow-up testing completion ranged from 41.5% (HIV) to 26.4% (syphilis). CONCLUSIONS: Residents rated precepting as the most effective training. However, DUE demonstrated that PrEP underuse, as well as suboptimal testing, limited experiential training on CDC guidelines. Curricular updates should further emphasize appropriate patient selection for PrEP, including women, minorities, and PWID, as well as robust testing, to continue expanding PrEP access.