Impact of Dosing Conversion From Basal Insulin to Follow-On Insulin Glargine.

BACKGROUND: Several basal insulins have recently come to market including follow-on insulin glargine (Basaglar®). Currently, there is no real-world data published on the implications of conversion to Basaglar on dosing or glycemic control. OBJECTIVE: To identify differences in basal insulin dosing requirements, hemoglobin A1c (HbA1c), and incidence of hypoglycemia or weight gain when converting a patient to Basaglar from another basal insulin. METHODS: Single-center, retrospective chart review at an academic medical center. All patients prescribed Basaglar between December 15, 2016, and August 31, 2017 were included for review if converted from another basal insulin. PRIMARY OUTCOME: Difference in basal insulin requirements in both units/d and units/kilogram (kg)/d after conversion to Basaglar. SECONDARY OUTCOME: Change in HbA1c and weight. RESULTS: Mean basal insulin dose was 38.4 ± 26.3 units/d pre-conversion and 40.5 ± 29.8 units/d post-conversion (P = .031). Results were significant for patients with type 2 diabetes mellitus (T2DM; pre-conversion basal dose 34.6 ± 24.3 units/d; post-conversion basal dose 37.6± 29.0 units/d; P = .009). Weight-based dosing changed from 0.37 ± 0.25 units/kg/d pre-conversion to 0.39 ± 0.29 units/kg/d post-conversion (P = .056) and was significant for patients with T2DM (P = .040). A nonsignificant decrease in HbA1c was seen (-0.14% ± 1.24%; P = .142). There was no difference seen in weight (111.6 ± 46.3 kg vs 111.7 ± 46.9 kg; P = .662). CONCLUSION: Patients with diabetes require similar basal insulin doses upon conversion to Basaglar. Clinicians should monitor blood glucose closely during basal insulin transition.

Evaluation of Clinical Pharmacist Services in a Transitions of Care Program Provided to Patients at Highest Risk for Readmission.

BACKGROUND: An ambulatory transition of care program, including a pharmacist-provided comprehensive medication review (CMR), was implemented. OBJECTIVES: The objectives were to: (1) compare 30-day hospital readmission rates between those who received the pharmacist CMR versus eligible patients not scheduled, (2) describe identified problems and recommendations, and (3) quantify recommendation acceptance rates. METHODS: A retrospective cohort study was conducted between March and October 2016. Inclusion criteria were: LACE score of ≥13, established Michigan Medicine primary care, and discharged from specific inpatient services to home. The primary outcome was 30-day hospital readmission rates. Pharmacist-identified problems, recommendations, and recommendation acceptance rates were examined. χ2 analysis and descriptive statistics were used. RESULTS: 355 discharges met inclusion criteria and pharmacists provided CMRs for 159 patients. The average age was 60 years (standard deviation [SD]: 14.3), the majority were female (54%), and white/Caucasian (69%). There was no significant difference in 30-day readmission rates in patients who received a CMR (p = .96). A mean of 3.1 problems were identified per visit (SD: 1.8, range: 1-10). 509 recommendations were provided and approximately 50% were provider accepted. CONCLUSIONS: Reduced readmission rates were not observed; however, pharmacists identified many areas for intervention in highest risk patients during the transition from hospital to home.

A randomized controlled trial of empiric warfarin dose reduction with the initiation of doxycycline therapy.

BACKGROUND: When interacting medications, such as doxycycline, are initiated during warfarin therapy, one method to correct for non-therapeutic international normalized ratio (INR) is adjusting the warfarin dose, if necessary. Another approach is preemptive warfarin dose adjustment. This study's objective was to evaluate the utility of preemptive warfarin dose adjustment for preventing non-therapeutic INR following doxycycline-warfarin co-administration. METHODS: Patients were randomized to either a 10% to 20% preemptive warfarin dose reduction (intervention) or reactive warfarin dose adjustment (control) within 72 hours of warfarin-doxycycline co-administration. Subjects received a follow-up INR within 7 days (index INR). Primary outcome was the occurrence of index INR ≥ 1 point over the INR goal range upper limit. Secondary outcomes included INR control, purchases of prescription vitamin K, and warfarin-associated adverse events in the 30 days after doxycycline initiation. RESULTS: Twenty and 17 patients comprised the intervention and control groups. The intervention group's warfarin dose was reduced by a median of 11%. More control patients (n=2) experienced an INR ≥ 1 point over the INR goal range upper limit compared to intervention (n=0); however, the difference (12% vs. 0%) was not statistically significant (p=0.20). A higher percentage of intervention patients had subtherapeutic index INRs compared to control (35% vs. 6%, p<0.05). One patient from each group experienced warfarin-associated bleeding. No thromboembolic complications or vitamin K use were observed. CONCLUSIONS: For warfarin patients initiating doxycycline therapy, preemptive warfarin dose reduction did not result in supratherapeutic INRs but increased the likelihood of subtherapeutic INRs compared to INR monitoring with reactive warfarin dose adjustment.