ß-Blockers and the Rate of Chronic Obstructive Pulmonary Disease Exacerbations.

Objective: To review the rate of exacerbations relative to ß-blocker use in patients with chronic obstructive pulmonary disease (COPD). Data Sources: A MEDLINE search (1953 to May 2019) was performed using the search terms beta-blockers, chronic obstructive pulmonary disease, and exacerbations. An EMBASE search was also performed using the search terms chronic obstructive lung disease and beta adrenergic receptor blocking agents (1970 to May 2019). References from the review of literature citations were also identified. Study Selection and Data Extraction: English-language studies assessing COPD exacerbations in patients prescribed a ß-blocker were included. Any article not addressing exacerbations was excluded. Data Synthesis: A total of 15 articles were included; 7 articles showed no change, 1 provided mixed results, and 7 indicated a significant decrease in COPD exacerbations in a variety of exacerbation severities. Two of the studies differentiated between cardioselective and noncardioselective ß-blockers. Relevance to Patient Care and Clinical Practice: This work represents an initial assessment of the use of ß-blockers to reduce COPD exacerbations. The findings raise the question if ß-blockers should be used more frequently in patients with COPD. Conclusions: Based on the limited number of studies that address ß-blocker use in COPD, it appears that exacerbations are not increased and may be decreased. A randomized, placebo-controlled trial is in progress to possibly provide more definitive answers to this question. Until the trial is complete, ß-blockers should not be withheld in COPD patients who have concurrent cardiovascular conditions, especially where there is a mortality benefit.

Evaluation of a Pharmacist-Driven Protocol to Reduce Inappropriate Use of Acid-Suppressive Medications In the Non-ICU Setting.

PURPOSE: Proton pump inhibitors (PPIs) and histamine-2 receptor antagonists (H2 blockers) continue to be over utilized for stress ulcer prophylaxis (SUP). Our study aims to evaluate the effectiveness and feasibility of a pharmacist-driven termination protocol in a community teaching hospital to limit the inappropriate use of acid-suppressive medications in the non-intensive care unit (ICU) setting. METHODS: Patient charts were evaluated for the appropriate use of PPIs or H2 blockers. A centralized pharmacist contacted healthcare providers for medication discontinuation if the acid suppressant use was deemed inappropriate. The primary outcome of the study was the number of patients who had acid-suppressive medication discontinued after the implementation of the pharmacist-driven termination protocol. RESULTS: Acid-suppressive medication was inappropriately prescribed for nine patients. It was discontinued for eight of those patients based on the pharmacist-driven termination protocol; this was a statistically significant decrease (P < 0.001). The pharmacist spent, on average, less than one minute on each patient's chart. CONCLUSION: Our study revealed that a pharmacist-driven termination protocol resulted in a 6% overall reduction rate in inappropriately used acid-suppressive medications, with little impact on pharmacist workflow. Implementing such a termination protocol could help to decrease the inappropriate use of acid-suppressive medications in an inpatient hospital service.

Pharmacists' Knowledge of the Cost of Laboratory Testing.

Purpose: The objective of this study was to ascertain baseline knowledge of pharmacists and pharmacy residents concerning the cost of laboratory tests for monitoring medications, and to determine whether an educational session delivered to pharmacy residents improves their knowledge of these costs. Methods: An online survey was provided to pharmacists and pharmacy residents, testing their knowledge of 15 common laboratory tests used to monitor the safety and efficacy of medications. One of the researchers presented a lecture to all pharmacy residents that detailed individual laboratory costs; after that, the researchers delivered a follow-up survey to assess the effectiveness of the educational session. Results: Baseline knowledge of pharmacists showed that greater than 64% of the responses were more than 30% away from the actual cost of the laboratory test for all 15 tests. Baseline knowledge of pharmacy residents showed that greater than 58% of the responses were more than 30% away from the actual cost of the laboratory test for each individual test. Although there was no statistically significant improvement in individual cost prediction after the educational session, 2 laboratory values showed improvement in margins of error post intervention: alanine aminotransferase/aspartate aminotransferase and lipids (P = .008 and .014, respectively). Conclusions: Pharmacists and pharmacy residents poorly predicted the costs of common laboratory tests. A brief lecture discussing the cost of laboratory tests demonstrated minor improvement in pharmacy residents' knowledge of the costs reviewed. Pharmacists need to be educated on the cost of laboratory tests to better understand the profession's contribution to health care expenditures.

Rare Red Rashes: A Case Report of Levetiracetam-Induced Cutaneous Reaction and Review of the Literature.

Cutaneous reactions secondary to medications are rare but can be serious events resulting in morbidity and mortality and can be caused by anticonvulsant medications. Levetiracetam has been considered relatively safe compared with other antiepileptics with regard to skin eruptions. We report a case of a cutaneous reaction secondary to levetiracetam. A 64-year-old man presented to the hospital with an altered mental status and aphasia. Imaging revealed a left basal ganglia mass. A biopsy of the lesion was obtained, and levetiracetam was started at 500 mg intravenously twice a day for seizure prophylaxis. After 13 doses, the patient developed a diffuse, erythematous, warm, blanching, morbilliform rash. Levetiracetam was discontinued, and methylprednisolone was started. After 4 days, the rash dissipated. Levetiracetam is an antiepileptic medication that has an unknown mechanism of action. To date, there are only 4 cases reported involving skin reactions from levetiracetam. Two of the cases were classified as Stevens-Johnson Syndrome: 1 as toxic epidermal necrolysis and 1 as erythema multiforme. Our case was classified as a morbilliform rash. A Naranjo score of 7 suggested a probable cause for a levetiracetam-induced skin reaction. Antiepileptic medications are used in certain cases to prevent seizures in patients with central nervous system tumors. Although levetiracetam seems to have fewer side effects than the traditional antiepileptic medications, it is important for the healthcare provider to continuously evaluate the need for all medications and discontinue unneeded ones to help avoid potential medication adverse effects.

Gabapentin: Abuse, Dependence, and Withdrawal.

OBJECTIVE: To identify case reports and studies regarding patients who abused, became dependent on, or experienced withdrawal from gabapentin. DATA SOURCES: A PubMed literature search (1993 to October 2015) was performed using the search terms gabapentin, withdrawal, dependence, and addiction. Additional references were identified from a review of literature citations. STUDY SELECTION: All English-language case reports and studies were evaluated. DATA SYNTHESIS: A total of 18 case reports or case series were identified regarding addiction to or withdrawal from gabapentin. All the cases of addiction were in patients who had a previous history of alcohol, cocaine, or opioid abuse. On average, the patients were taking more than 3000 mg/d (600-8000 mg/d). Two surveys reported that the misuse of gabapentin was 1.1% in the general population and 22% in drug abuse treatment centers. Withdrawal, when reported, occurred within 12 hours to 7 days of discontinuation of the medication. CONCLUSION: There have been numerous documented cases of gabapentin abuse, dependence, and withdrawal. Even though gabapentin is sometimes considered as a treatment option for alcohol and substance abuse, it is important to monitor for drug-seeking behaviors. A history of alcohol or substance abuse appears to be an important part of a patient's medical history when evaluating their risk for addiction and dependence behaviors. Health care providers need to be aware of this risk in their patients and monitor their patients for signs of abuse and dependence along with withdrawal symptoms.

Psychosis induced by zonisamide: a case report and review of the literature.

Zonisamide is an anti-seizure medication that is indicated for adjunctive therapy in the treatment of partial seizures. This medication is rarely used in the United States. An infrequent adverse effect of psychosis occurs in about 2% of patients taking zonisamide. This is a case report of a 34-year-old male on phenytoin who presented with psychosis symptoms approximately 10 months after starting adjunctive zonisamide.

Value of the student pharmacist to experiential practice sites: a review of the literature.

OBJECTIVE: To summarize the literature addressing clinical services provided by pharmacy students and the economic implications associated with those services. DATA SOURCES: A literature search was performed through MEDLINE and International Pharmaceutical Abstracts from their inception through December 2011. Search terms included pharmacy students, doctor of pharmacy students, clinical interventions, documentations, and medication histories. STUDY SELECTION AND DATA EXTRACTION: All research articles and abstracts published in English were included. Studies were excluded if they were not conducted in the US. Articles were reviewed and abstracted for number of interventions and proportion of total interventions performed by pharmacy students, type and duration of advanced practice experience, patient care location, time required for interventions, frequency of interventions that were accepted or implemented, and financial assessment of interventions when reported. DATA SYNTHESIS: A total of 29 fully published studies and 6 abstracts were identified. The majority of the studies evaluated the number of student recommendations made and the acceptance rate of those recommendations. On average, individual students made between 1.2 and 16 recommendations to prescribers per week. The acceptance rate ranged from 32% to 98%. In addition to recommendations, students performed intravenous to oral dose conversions and obtained medication histories. All of the studies that assessed the economic impact of student pharmacist involvement reported a cost savings or cost avoidance associated with having pharmacy students at the institution. CONCLUSIONS: Pharmacy students provide many recommendations with high acceptance rates. During their pharmacy practice experiences, students generally confer economic and clinical benefits that may exceed the costs associated with their supervision and training.

Utility of a Diabetes Medication Poster in a Primary Care Clinic.

BACKGROUND: Diabetes with related complications is a common disease state seen in primary care and available therapies have increased exponentially. It is difficult for a busy primary clinician to know and utilize these options efficiently. OBJECTIVE: The objective was to determine whether creating a diabetes medication poster that included costs, drug classification, adverse effects, and clinical outcomes/contraindications/cautions for use in an internal medicine/medicine-pediatric clinic improves resident and faculty knowledge, comfort, and awareness of those medications. METHODS: This quality improvement prospective study was designed to evaluate the utility of a diabetes medication poster in a medicine/medicine-pediatric clinic over a 2-month period. A pre and post survey was electronically sent to all residents and faculty to assess their level of confidence and knowledge of diabetes medication treatment before and after the poster was distributed. This study was classified as exempt by the Institutional Review Board. RESULTS: There were 40 physicians that responded to the pre survey and 31 to the post survey. Both surveys revealed >90% agreed or strongly agreed that the poster would decrease risk of adverse reactions, help control cost, and increase confidence to providers about diabetic medications. The knowledge score increased pre vs post survey (P = .0398). CONCLUSION: There are a myriad of tools that can be utilized to help navigate complex diseases. Posters have rarely been evaluated. Physicians viewed the diabetes medication poster as favorable to help decrease adverse effects and cost while increasing knowledge. Areas where visual aids could be effective without overwhelming the providers should be explored.

Factors influencing the involvement of doctor of pharmacy students in research and scholarship projects.

INTRODUCTION: The study objective was to determine factors that stimulate or hinder student pharmacist participation in research and scholarship, to determine factors faculty believe are motivators or barriers for student pharmacist participation, and to compare student and faculty responses. METHODS: An electronic questionnaire was developed and emailed to all students enrolled in the doctor of pharmacy program and to all program faculty. To increase response rate, students were provided class time to complete the survey. Responses were collected anonymously. RESULTS: A total of 404 students (69% response rate) and 35 faculty (78% response rate) participated. Motivational factors rated highly by both students and faculty were interest in the topic, comfort level in working with faculty, energetic quality of faculty, and becoming more competitive for post-graduate training. Students indicated that projects benefiting the profession/medical community was an important motivator, while faculty believed that pursuing a position that requires research/scholarship was a key motivational factor. The most highly rated barrier was lack of time. CONCLUSIONS: Student pharmacist participation in research and scholarship with faculty is variable in our program and little was known previously about factors that led student pharmacists to engage in research and scholarship. There was general agreement among student and faculty regarding several motivating factors; however, some important differences did exist. Addressing these differences may help increase student involvement in research and scholarship in the future.

Accidental overdose of tiotropium in a patient with atrial fibrillation.

OBJECTIVE: To report a case of refractory tachycardia after an excessive dose of inhaled tiotropium. CASE SUMMARY: A 74-year-old male with atrial fibrillation was admitted for increased heart rate and shortness of breath. The patient's heart rate was initially stabilized between 80 and 90 beats/min with metoprolol succinate 50 mg daily. During hospitalization, he accidentally received 5 capsules of tiotropium 18 microg inhaled as a single dose (total 90 microg) and, approximately 15 minutes later, his heart rate increased from 80 to 160 beats/min. Over 5 days of hospitalization, the patient's tachycardia was difficult to control and he required multiple atrioventricular (AV) nodal blocking agents (physostigmine, metoprolol tartrate, diltiazem) for effective stabilization prior to discharge. On outpatient follow-up 11 days after the ingestion the patient's heart rate was in the 40s and the AV nodal blocking agents were proportionately decreased. DISCUSSION: Tiotropium is a long-acting anticholinergic medication used to treat chronic obstructive pulmonary disease. Little has been reported as to the potential systemic toxicities of tiotropium. Tachycardia is listed as a potential adverse effect, but based on a MEDLINE search (1966-July 2009) using tiotropium, tachycardia, and overdose as search terms, there have been no case reports published. Renal impairment may increase plasma concentrations of tiotropium; our patient's creatinine clearance was estimated to be below 50 mL/min. According to the Naranjo probability scale, our patient's development of tachycardia was probably associated with tiotropium inhalation. CONCLUSIONS: Tiotropium can be temporally implicated in a rapid heart rate following excessive ingestion. Health care professionals should be aware of tachycardic effects of tiotropium, particularly in patients with underlying structural heart disease, atrial fibrillation, and renal impairment.

Prevalence of and risk factors for dysglycemia in patients receiving gatifloxacin and levofloxacin in an outpatient setting.

STUDY OBJECTIVES: To assess the prevalence of dysglycemia (hypoglycemia or hyperglycemia) associated with oral levofloxacin and gatifloxacin therapy in an outpatient setting, and to determine the characteristics of patients who developed dysglycemia while receiving either fluoroquinolone. DESIGN: Retrospective medical record review. SETTING: Outpatient clinic of a Veterans Affairs teaching hospital. PATIENTS: A total of 1573 patients who received oral levofloxacin (343 patients), gatifloxacin (589 patients), or azithromycin (as a control, 641 patients) between June 1, 2004, and May 31, 2006. MEASUREMENTS AND MAIN RESULTS: Dysglycemia occurred in 33 patients: 13 (2.2%), 9 (2.6%), and 11 (1.7%), respectively, of those in the gatifloxacin, levofloxacin, and azithromycin groups. Of 13 patients who experienced a hyperglycemic event, 11 (84.6%) had diabetes mellitus. After adjustment for confounding factors, neither levofloxacin nor gatifloxacin were associated with increased odds of developing a dysglycemic event compared with azithromycin. Multivariate analysis demonstrated that lack of downward dosage adjustment based on creatinine clearance (odds ratio [OR] 10.3, 95% confidence interval [CI] 3.8-27.6), presence of diabetes (OR 17.1, 95% CI 3.1-94.9), or treatment with insulin (OR 5.3, 95% CI 1.8-15.7) or sulfonylureas (OR 3.6, 95% CI 1.3-10.4) independently increased dysglycemia risk. Obesity (body mass index > or = 30 kg/m(2)) was independently protective (OR 0.22, 95% CI 0.09-0.55) against dysglycemic events. CONCLUSION: Levofloxacin and gatifloxacin were not significantly associated with increased dysglycemic events compared with azithromycin. Lack of downward fluoroquinolone dosage adjustment for renal function, presence of diabetes, and treatment with insulin or sulfonylureas each independently increased the risk of dysglycemia. Obesity was independently protective against dysglycemia. More data are needed on the contributing effects of diabetes, fluoroquinolone dosage, and concomitant drug therapy so that an appropriate risk-management strategy can be developed.

"Ping-pong gaze" secondary to monoamine oxidase inhibitor overdose.

An infrequent manifestation of monoamine oxidase inhibitor (MAOI) toxicity is "ping-pong gaze" (PPG). We describe the case of a 26-year-old female who was found unresponsive after taking 40 tablets of phenelzine. On presentation to the hospital, her eyes were moving in characteristic "ping pong" fashion. After 6 hours her gaze terminated. The following day her neurologic exam was benign and she had no long-term sequelae. While the etiology of PPG is unknown, it is most often seen with irreversible structural brain damage. However, a detailed literature review revealed that previous cases of MAOI toxicity where the patient survived have all had complete neurologic recovery.

Hyperglycemia and gatifloxacin: a case report and summary of current literature.

BACKGROUND: Gatifloxacin is a widely used fluoroquinolone antibiotic. Several case reports have described hyperglycemia that is related to gatifloxacin use. OBJECTIVE: Our goal was to report a new case of gatifloxacin-related hyperglycemia in a nondiabetic patient with acute renal dysfunction. Also summarized are data from existing case reports. CASE SUMMARY: A 71-year-old man with a history of coronary artery disease was admitted for saphenous vein harvest site infection, atrial fibrillation, postoperative Dressler's syndrome, and resolving acute renal failure after coronary artery bypass graft 10 days prior. His history was notable for the absence of diabetes mellitus. Four days after initiating gatifloxacin 400 mg/d for a wound infection and 3 days after an increase in serum creatinine to 2.8 mg/dL, his fasting serum glucose level was elevated to 209 mg/dL on routine laboratory evaluation. Standard dose sliding scale insulin was begun to control the patient's blood glucose, and his gatifloxacin dose was lowered to 200 mg/d due to his diminished renal function. The patient's blood glucose levels normalized rapidly after his course of gatifloxacin was completed. DISCUSSION: Thirteen cases of gatifloxacin-related hyperglycemia have been reported in the medical literature, 10 of which were in nondiabetic patients and at least 9 of which were in patients with creatinine clearance levels <50 mL/min. Although the mechanism for the adverse effect is poorly understood, it appears to be dose dependent and more likely to occur in patients with renal insufficiency. CONCLUSION: In this patient with impaired renal function, gatifloxacin was probably associated with hyperglycemia.

Bullous pemphigoid associated with dipeptidyl peptidase IV inhibitors. A case report and review of literature.

BACKGROUND: Bullous pemphigoid is a cutaneous autoimmune blistering disorder. The etiology for what precipitates this disease is not entirely clear at this point, although it has been associated with certain medications. MAIN OBSERVATION: We describe the case of a 70-year-old male with a past medical history of diabetes type 2 who developed a diffuse eruption of bullae with skin biopsy positive for bullous pemphigoid. He had previously been prescribed sitagliptin 50 mg daily for at least one year prior to onset of his disease. The medication was discontinued and the patient was treated with first IV and then oral steroids with good clinical outcome. There have been a few reports that have explored the relationship between DPP-IV inhibitors (gliptins) and bullous pemphigoid, including three case series and a report on sitagliptin associated allergic skin reactions submitted to the Adverse Event Reports System database of the FDA. According to the Naranjo ADR probability score there is a "possible" cause and effect relationship for this case. CONCLUSION: The enzyme DPP-IV is ubiquitously expressed in almost every organ system, including the skin. The exact mechanism at this time is unknown but is believed to be multifactorial involving many aspects of the immune system. Our case and the findings from our literature review further demonstrate a link between dipeptidyl peptidase-IV inhibitors and the development of bullous pemphigoid.

Severe adverse skin reactions to nonsteroidal antiinflammatory drugs: A review of the literature.

PURPOSE: Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) associated with the use of nonsteroidal antiinflammatory drugs (NSAIDs) are described. SUMMARY: A search of the English- language medical literature was conducted to identify studies and cases of SJS and TEN associated with NSAIDs and cyclooxygenase-2-selective NSAIDs available in the United States. Several epidemiologic studies, case reports, and case series involving SJS and TEN associated with NSAIDs were identified. Of the available NSAIDs, oxicam derivatives appeared to have the greatest association with SJS and TEN. The relative risks reported with other NSAIDs are much lower. The risk with cyclooxygenase-2-selective NSAIDs and meloxicam is less clear, since all were introduced after the completion of the epidemiologic studies. SJS or TEN from NSAIDs and cyclooxygenase-2-selective NSAIDs appears to affect the same patient population as other medications that cause SJS or TEN. The risk of SJS or TEN caused by NSAIDs is extremely low (less than 2 per 1 million users per week for oxicam derivatives, less than 1 per 1 million users per week for other NSAIDs, and 6 cases per 1 million person-years for celecoxib). Aspirin is not typically associated with SJS or TEN. Of the other salicylates, SJS or TEN has only been reported with diflunisal. CONCLUSION: The risk of SJS or TEN in patients receiving NSAIDs is extremely low; older patients, women, and patients within the first month of treatment initiation appear to have the greatest risk. Health care providers and patients should be aware of the signs and symptoms of SJS and TEN.