Thiazide Diuretic-Induced Change in Fasting Plasma Glucose: a Meta-analysis of Randomized Clinical Trials.

BACKGROUND: Prior meta-analyses measuring thiazide-induced glycemic change have demonstrated an increased risk of incident diabetes; however, this measure's definition has changed over time. AIM: To determine the magnitude of change in fasting plasma glucose (FPG) for thiazide diuretics. DATA SOURCES: A research librarian designed and conducted searches in Medline®, EMBASE, and EBM Reviews-Cochrane Central Register of Controlled Trials (inception through July 2018) and International Pharmaceutical Abstracts (inception to December 2014). STUDY SELECTION: Randomized, controlled trials comparing a thiazide or thiazide-like diuretic to any comparator reporting FPG were identified. Trials enrolling < 50 participants, those with a follow-up period of < 4 weeks, and conference abstracts were excluded. DATA EXTRACTION: Independent duplicate screening of citations and full-text articles, data extraction, and assessment of risk of bias was conducted. DATA SYNTHESIS: Ninety-five studies were included (N = 76,608 participants), with thiazides compared with placebo, beta-blockers, calcium channel blockers, renin-angiotensin-aldosterone-system inhibitors, potassium-sparing diuretic, and others alone or in combination. Thiazide diuretics marginally increased FPG (weighted mean difference 0.20 mmol/L (95% CI 0.15-0.25); I2 = 84%) (1 mmol/L = 18 mg/dL). Results did not change substantially when considering dose or duration, comparing thiazides with placebo or an active comparator, or using thiazides as monotherapy or combination therapy, even when combined with a potassium-correcting agent. CONCLUSION: Thiazide diuretics have a small and clinically unimportant impact on FPG.

Interaction Between Low-Dose Methotrexate and Nonsteroidal Anti-inflammatory Drugs, Penicillins, and Proton Pump Inhibitors.

OBJECTIVE: To review the potential drug interactions between low-dose methotrexate (LD-MTX) and nonsteroidal anti-inflammatory drugs (NSAIDs), penicillins, and proton-pump inhibitors (PPIs) given the disparity between interactions reported for high-dose and low-dose MTX to help guide clinicians. DATA SOURCES: A literature search was performed in MEDLINE (1946 to September 2016), EMBASE (1974 to September 2016), and International Pharmaceutical Abstracts (1970 to January 2015) to identify reports describing potential drug interactions between LD-MTX and NSAIDS, penicillins, or PPIs. Reference lists of included articles were reviewed to find additional eligible articles. STUDY SELECTION AND DATA EXTRACTION: All English-language observational, randomized, and pharmacokinetic (PK) studies assessing LD-MTX interactions in humans were analyzed to determine clinical relevance in making recommendations to clinicians. Clinical case reports were assigned a Drug Interaction Probability Scale score. DATA SYNTHESIS: A total of 32 articles were included (28 with NSAIDs, 3 with penicillins, and 2 with PPIs [1 including both PPI and NSAID]). Although there are some PK data to describe increased LD-MTX concentrations when NSAIDs are used concomitantly, the clinical relevance remains unclear. Based on the limited data on LD-MTX with penicillins and PPIs, no clinically meaningful interaction was identified. CONCLUSION: Given the available evidence, the clinical importance of the interaction between LD-MTX and NSAIDs, penicillins, and PPIs cannot be substantiated. Health care providers should assess the benefit and risk of LD-MTX regardless of concomitant drug use, including factors known to predispose patients to MTX toxicity, and continue to monitor clinical and laboratory parameters per guideline recommendations.

Professional Fulfillment and Burnout in Fourth-Year Pharmacy Students and Risk Factors for the Future: A Mixed Methods Study.

OBJECTIVE: Many factors shape the professional identity of pharmacy students; however, little is known about the influence of well-being. Two aspects of well-being explored in this study include professional fulfillment and burnout. We describe the current levels of each among fourth-year pharmacy students, identify possible predictors, and uncover themes. METHODS: The Stanford Professional Fulfillment Index was used to measure professional fulfillment and burnout among students in the prior 2 weeks. Multivariable linear regressions were conducted to identify individual characteristics and activities as predictors of professional fulfillment and burnout. Upon completion of activities to foster personal wellness, student self-reflections were analyzed using thematic analysis to describe student-perceived barriers and facilitators of professional fulfillment and burnout. RESULTS: In total 54 students completed the Professional Fulfillment Index, wellness activities, and self-reflection. Having already completed the jurisprudence examination required for licensure and having a job upon graduation were statistically significantly associated with higher professional fulfillment scores. We identified that working in a non-pharmacy-related job, while completing practicums, was statistically significantly associated with higher work exhaustion scores. Themes uncovered from student self-reflections included a definition of wellness, how doing what you are supposed to be doing and working in a psychologically and physically safe environment contributes to professional fulfillment, and system-level factors leading to burnout. CONCLUSION: This study provides evidence of the importance of supporting pharmacy students in the completion of the steps to licensure, the value of exposure to a variety of pharmacist-related activities through experiential education, and well-being as foundational to professional identity.

The impact of the COVID-19 pandemic on pharmacy students' personal and professional learning.

INTRODUCTION: The COVID-19 pandemic impacted both healthcare delivery and the education of healthcare students, with a shift to remote delivery of coursework and assessment alongside the expansion of the scope of practice of Alberta pharmacists. The objective of this research was to understand how the learning of pharmacy students at the University of Alberta was impacted by the COVID-19 pandemic. METHODS: A cross-sectional survey was distributed to 397 pharmacy students in years one through three. Students responded to three short-answer reflection questions: (1) how has the COVID-19 pandemic situation affected your learning; (2) from a pharmacy and pharmacy school perspective, what have you learned since the COVID-19 pandemic began; and (3) from a personal perspective, what have you learned about yourself since the COVID-19 pandemic began? A thematic analysis was undertaken of students' responses to these reflection questions. RESULTS: A total of 53 students responded to the survey (response rate 13%). Two major themes were identified across all three reflection questions, with several subthemes: remote learning (learning environment, knowledge transfer, knowledge retention, assessment) and mental health (appreciation, stress, extroversion, motivation). Adaptability, routine, professional identity, and the role of the pharmacist were also identified as less prevalent themes. CONCLUSIONS: Pharmacy students' responses led to the identification of several themes related to their learning given the changes brought about by the COVID-19 pandemic. This increased understanding of student perceptions has the potential to improve the remote delivery of education, support increased university-wide mental health resourcing, and shape pharmacy curriculum development.

Admissions processes in North American pharmacy schools: To what extent are characteristics of practice success measured?

INTRODUCTION: The goal of preparing competent pharmacy practitioners starts with the admissions process, whereby skills and abilities can be screened to identify those individuals with a strong potential for success. This study sought to describe the admissions processes of top pharmacy schools in North America and identify the extent to which characteristics associated with professional success are measured. METHODS: An observational survey design was used to collect information to help characterize the admissions processes of 60 pharmacy schools. Online and centralized Pharmacy College Application Service data of admissions requirements were confirmed and further details were collected through a telephone or email cross-sectional survey. Data were analyzed using descriptive statistics. RESULTS: Online data indicate that every school (n = 60) requires prerequisite courses; 53 (88%) consider grade point average (GPA) and 45 (75%) consider the Pharmacy College Admission Test (PCAT). Most schools utilize interviews during admissions (94%), with 67% using a personal interview, 20% the Multiple Mini Interview (MMI), and 7% a combination of both. Of 60 schools contacted, 42% completed the survey. Most schools (92%) assess critical thinking and professional motivation; the personality traits of agreeableness and conscientiousness were considered by 83%. Personal interview was the most frequently cited method for assessing applicant characteristics. CONCLUSION: Current admissions practices in the top North American pharmacy schools are varied and continue to rely on traditional components including GPA, PCAT, and interviews. However, there is also a movement toward using standardized and validated measures of non-cognitive aspects potentially more predictive of success in pharmacy school and subsequent practice.

Patient Satisfaction with Pharmacist-Led Collaborative Follow-Up Care in an Ambulatory Rheumatology Clinic.

OBJECTIVES: Patient satisfaction is known to increase with pharmacist intervention in general outpatient clinics and with nurse-led care in rheumatology clinics. The aim of the present study was to describe and compare patient satisfaction with two different types of care: a pharmacist physician collaborative model and a traditional physician model in a rheumatology clinic setting. METHODS: A cross-sectional survey of inflammatory arthritis patients seen during a follow-up visit in Edmonton, Alberta, Canada, was conducted over a ten-week period. Patient satisfaction was measured using a modified version of the validated Leeds Satisfaction Questionnaire, which uses a five-point Likert scale to measure six dimensions of satisfaction, and compared between the collaborative care and traditional physician models. RESULTS: A total of 62 patients completed the questionnaire (21 collaborative care and 41 traditional physician model). The average age of respondents was 52 years and the majority were female. The mean score for satisfaction across the six dimensions was 4.56 in the collaborative care group and 4.30 in the traditional physician group (p = 0.02). Patient satisfaction in the collaborative care group was consistently higher across all dimensions. No difference was noted between participants seen for the first time compared with those seen two or more times by the pharmacist. CONCLUSIONS: A collaborative care model can exceed the already high expectations for care of patients with inflammatory arthritis. Our findings support the role of pharmacists using a collaborative care approach to care for patients in rheumatology clinics.

Self-reported use of natural health products among rheumatology patients: A cross-sectional survey.

OBJECTIVES: To describe the self-reported use of natural health products (NHPs) and identify characteristics that predict selected NHP use in rheumatology patients. METHODS: We conducted a cross-sectional survey of consecutive rheumatology patients in two major clinics in Edmonton, Alberta. Survey items included demographic data, rheumatologic diagnoses, prescribed medications, NHPs, and information regarding patients' use of NHPs. Selected NHPs of interest - defined to include joint-specific products, oils with putative joint benefits, and other non-vitamin, non-mineral products - were classified by 2 reviewers. The characteristics of selected NHP users and non-users were compared using chi-squared and ANOVA tests, followed by multivariable-adjusted logistic regression. RESULTS: 1063 patients completed the survey (response rate = 36%, mean age 53 [sd 15], 70% female). 36% of respondents reported using one or more of a wide range of selected NHPs (mean 1.8, range 1-9). The most common source of NHP recommendations for selected NHP users were physicians (42%). Significant predictors of selected NHP use were: being female (aOR 1.41, 95%CI [1.05-1.90], p = 0.02), having a post-secondary degree (aOR 1.60 [1.15-2.22], p = 0.005), and the number of non-rheumatic medications (aOR 1.08 [ 1.00-1.15], p = 0.03) and NSAIDs (aOR 1.32 [1.06, 1.63], p = 0.01). Similar findings were observed among only inflammatory arthritis patients. CONCLUSIONS: Our study confirms the frequent use of selected NHPs, possibly to mitigate persistent symptoms of rheumatologic illness. Rheumatologists appear to be trusted sources of advice and recommendations on NHP use and should provide balanced counselling for their patients.

Clinical effectiveness and safety of leflunomide in inflammatory arthritis: a report from the RAPPORT database with supporting patient survey.

Leflunomide is indicated for the treatment of adults with rheumatoid arthritis, yet is underutilized. Given the cost of biologic therapy, understanding real-life effectiveness, safety, and sustainability of leflunomide, particularly in patients who have failed methotrexate, would be of value. The primary objective was to assess the proportion of patients achieving clinically meaningful benefit following an adequate trial of leflunomide. A retrospective analysis of a cohort supplemented with patient self-reported data using a standardized questionnaire. Data were analyzed using descriptive statistics, with a database multivariate logistic regression analysis to determine predictors of leflunomide response. Of the cohort available (N = 2591), 1671 patients with confirmed leflunomide use were included in the retrospective analysis, of whom 249 were incident users. Low disease activity (DAS-28 < 3.2) was achieved or maintained by 20% of incident users, with 19% achieving a clinical response (DAS-28 decrease ≥1.2) at 3 months. Adverse effects (AE) were reported by 29% of incident users and after 1 year, 45% remained on leflunomide. Achievement of "minimal or no joint symptoms" was reported by 34% in the 661 analyzable survey responses (39% response rate). AE were reported by 55%, with nuisance (hair loss, nausea, stomach pain) AE and diarrhea being most common. Leflunomide was discontinued by 67% of responders within 1 year. An important proportion of patients, the majority of whom had previously failed methotrexate, achieved disease response with leflunomide with a low risk of serious adverse effects, suggesting that a trial of leflunomide may be a reasonable and cost-effective strategy prior to biologic therapy.

Medication transitions and polypharmacy in older adults following acute care.

BACKGROUND/OBJECTIVE: Medication changes at transitions of care and polypharmacy are growing concerns that adversely impact optimal drug use. We aimed to describe transitions and patterns of medication use before and 1 year after older patients were hospitalized for community-acquired pneumonia, the second-most common reason for admission in North America. MATERIALS AND METHODS: This was an analysis of a population-based clinical registry of patients treated in any of the six hospitals or seven emergency departments in Edmonton, Alberta, Canada, comprising 2,105 patients 65 years and older with community-acquired pneumonia who had survived at least 1 year. The prevalence of polypharmacy (five or more unique prescription drugs), as well as new use and persistence of common drug classes were assessed. RESULTS: The mean age was 78 years (standard deviation 8 years), 50% were female, 62% were hospitalized, and 58% had severe pneumonia. Among the 2,105 patients, 949 (45%) were using five or more medications prior to hospitalization, increasing to 1,559 (74%) within 90 days postdischarge and remaining over 70% at 1 year. Overall, 1,690 (80%) patients newly started and 1,553 (74%) patients stopped at least one medication in the first 90 days of follow-up. The prevalence of the most common drug classes (ie, cardiovascular, alimentary/metabolism) remained stable, with the exception of anti-infective agents, whereby 25% of patients were dispensed an anti-infective agent 3 months to 1 year after hospitalization. CONCLUSION: Most older patients with pneumonia are subject to polypharmacy, and almost every patient had a medication started or stopped during 1-year follow-up, with 25% using antibiotics again. The period following an episode of pneumonia represents an opportunity potentially to optimize pharmacotherapy.

Iatrogenic Cushing syndrome after intra-articular triamcinolone in a patient receiving ritonavir-boosted darunavir.

Drug interactions involving human immunodeficiency virus protease inhibitors are common due to their inhibition of the cytochrome P450 3A4 isoenzyme. We describe the case of an HIV-infected patient treated with ritonavir-boosted darunavir who developed cushingoid features following an intra-articular injection of triamcinolone acetate. We review the probable mechanism for this interaction and describe similar cases of Cushing syndrome in patients receiving concomitant ritonavir and triamcinolone.