Vitreous hemorrhage during GLP-1 receptor agonist treatment.

BACKGROUND: The purpose of this case report is to describe a case of vitreous hemorrhage in a patient with a history of diabetic retinopathy and receiving dulaglutide for the management of type 2 diabetes mellitus (T2DM). CASE SUMMARY: A 64-year-old African American male with a past medical history of T2DM and severe diabetic retinopathy for 4 years was restarted on dulaglutide 1.5 mg weekly after being off therapy for 3 months. Baseline laboratory test results included hemoglobin A1c (HbA1c) of 8.8% and random blood glucose (BG) of 280 mg/dL. In addition, the patient had an average fasting BG of 150 mg/dL. In absence of intolerance, the dulaglutide dose was gradually maximized to 4.5 mg weekly and HbA1c decreased to 7.3% and random BG to 121 mg/dL at week 12 since reinitiation. At week 17 of therapy, the patient presented to the emergency department with a 1-day history of vision loss in the left eye and was diagnosed as having vitreous hemorrhage. The etiology for vitreous hemorrhage is unclear and may be a spontaneous episode. In discussion with the patient and the ophthalmologist, dulaglutide was restarted at 1.5 mg once weekly. After 4 weeks of reinitiation, the patient denied any recurrent symptoms of vitreous hemorrhage or worsening diabetic retinopathy. The most recent ophthalmology evaluation indicated no change in diabetic retinopathy. PRACTICE IMPLICATIONS: This case report adds to the limited body of evidence available for the incidence of vitreous hemorrhage in the setting of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) therapy and pre-existing diabetic retinopathy. The case report illustrates that a history of diabetic retinopathy should not automatically preclude the use of GLP-1 RAs.

Serological response with Heplisav-B® in prior Hepatitis B vaccine non-responders living with HIV.

BACKGROUND: As people living with HIV (PLWH) are at risk for contracting Hepatitis B Virus (HBV), they should be screened for HBV and vaccinated if not immune. Seroconversion rates in PLWH receiving traditional recombinant HBV vaccines (Engerix-B® and Recombivax-HB®) have historically been low with at most 70% achieving immunity. In 2017, a recombinant, adjuvanted HBV vaccine (Heplisav-B®) was approved for use in HIV-negative patients. Heplisav-B® has shown superior seroprotection in this population compared to Engerix-B® and Recombivax-HB®, as well as interim analysis showing higher seropositivity rates in patients undergoing dialysis. However, its efficacy in PLWH is currently unknown. This study evaluates the rate of seroconversion following Heplisav-B® administration in PLWH with previous HBV vaccination failure. METHODS: Retrospective, cross-sectional study at The Brooklyn Hospital Center's HIV primary care clinic in Brooklyn, NY. HIV-positive adults who received at least two doses of Heplisav-B® and had previously failed to seroconvert after vaccination with Engerix-B® or Recombivax-HB® were included. The primary outcome is the percentage of PLWH who became seropositive following Heplisav-B®. RESULTS: A total of 67 patients met the inclusion criteria. Twenty-five (37.3%) PLWH had failed at least 2 courses of recombinant vaccines. Fifty-eight (86.6%) PLWH became seropositive (Anti-HBs > 10 mIU/mL) at least two months after completing Heplisav-B®. For the 9 (13.4%) patients that did not develop immunity, 3 (33%) had a detectable HIV RNA and 3 (33%) had a CD4 count < 200 cells/uL3. CONCLUSIONS: Heplisav-B® was highly effective in achieving immunity to HBV in PLWH who failed non-adjuvanted recombinant vaccines.

Evaluation of virologic suppression rates during the COVID-19 pandemic with outpatient interdisciplinary HIV care.

Introduction: The Coronavirus Disease 2019 (COVID-19) pandemic has presented social distancing challenges leading healthcare systems to adapt and utilize telemedicine platforms more than ever before. Reducing patient exposure to COVID-19 became a primary concern, especially for populations at an increased risk for severe illness, such as human immunodeficiency virus (HIV) positive patients. Objectives: The primary objective of this study was to measure the impact of pharmacy services including telehealth through the percentage of virologically suppressed patients (HIV ribonucleic acid [RNA] < 200 copies/mL) during the pre-COVID and post-COVID time periods. Secondary objectives included the percentage of patients with undetectable viral loads (HIV RNA < 20 copies/mL), percentage of patients with cluster of differentiation 4 (CD4) cell counts greater than 200 cells/mm3, and changes in CD4 cell counts and percentages pre-COVID and post-COVID. Methods: This was a retrospective chart review at a single center HIV primary care clinic in Brooklyn, NY evaluating electronic medical records (EMRs) of 211 HIV-positive patients. Pre-COVID was defined as 1 year prior to March 13, 2020, and post-COVID was defined as March 13 to July 20, 2020. Results: Viral load suppression rates for pre and post-COVID were 88.6% and 85.3%, respectively (P = .28). Undetectable viral load rates for pre and post-COVID were approximately 81.5% and 74.4% (P = .096). Mean CD4 cell counts and percentages were 617 cells/mm3 and 29% for pre-COVID, and 460 cells/mm3 and 22% for post-COVID. CD4 cell counts greater than 200 cells/mm3 pre-COVID and post-COVID was 92.6% and 78.3%, respectively (P = .001). Conclusion: Utilization of pharmacy services including telehealth, may allow clinical pharmacists to collaboratively provide remote services without jeopardizing patient outcomes. Larger studies are needed to confirm these findings, and display the long-term impact and satisfaction of these services.

Opioid-Induced Hyperalgesia in the Nonsurgical Setting: A Systematic Review.

BACKGROUND: Opioid-induced hyperalgesia (OIH) is a phenomenon that causes an increased pain sensitization and perception of pain to noxious stimuli secondary to opioid exposure. While this clinical effect has been described in the surgical setting, it is unclear if OIH occurs in the nonsurgical setting. STUDY QUESTION: To review the available literature which evaluated OIH in nonsurgical settings. DATA SOURCES: A comprehensive literature search was performed using PubMed (January 1946-July 2017) using a variety of keywords for OIH. This review included randomized controlled trials with objectives to identify OIH in the nonsurgical setting. The clinical outcomes of interest were identification of OIH, adverse events, and impact of OIH on opioid consumption. RESULTS: The search identified 8 studies that fulfilled the criteria. Six studies enrolled healthy male volunteers, 1 study used chronic low-back patients, and another used heroin-dependent treatment-seeking adults. Studies used various opioids and dosages, including remifentanil, alfentanil, fentanyl, morphine, methadone, and buprenorphine. Three primary experimental pain induction models were used to evaluate for OIH. Measured outcomes included hyperalgesia area, pain threshold, and pain tolerance. All 5 studies that used the electrical stimulation model identified OIH as a significant outcome. However, only 2 of 5 studies using the cold pressor model and 1 of 3 studies using the heat pressor model identified OIH. None of the trials explored clinical outcomes, such as effects on opioid consumption. CONCLUSIONS: Most included studies identified OIH as a significant outcome within the nonsurgical setting. However, due to conflicting conclusions and various limitations, the clinical impact of OIH could not be assessed. Clinicians should monitor for effects of OIH in the nonoperative setting because there is insufficient evidence from the available literature to conclude that OIH is consistently observed in this setting.