Real-world impact on monthly glucose-lowering medication cost, HbA1c, weight, and polytherapy after initiating a GLP-1 receptor agonist.

OBJECTIVE: Glucagon-like peptide-1 (GLP-1) receptor agonists are preferred injectable therapies for type 2 diabetes, but their high cost is an area of concern. This study evaluated monthly glucose-lowering medication cost and clinical impact after initiating a GLP-1 receptor agonist. DESIGN: A retrospective, pre-post cohort study evaluated monthly glucose-lowering medication cost, glycated hemoglobin (HbA1c), weight, and polytherapy impact (name, dose, and number of daily doses or injections) when a GLP-1 receptor agonist was initiated (baseline) and after 6-12 months (follow-up). The population was analyzed overall and as subgroups, based on baseline medication regimen and demographics. SETTING AND PARTICIPANTS: The study was performed at 8 ambulatory care sites (7 federally qualified health centers and a Program of All-Inclusive Care for the Elderly) in the greater Boston, MA, area. Patients were included in the analyses (n = 120) if they had a documented diagnosis of type 2 diabetes, were 18 years of age or older, had an HbA1c ≥ 7.5% measured within 3 months prior to the initiation of a GLP-1 receptor agonist, and an HbA1c measured 6 to 12 months following the initiation of a GLP-1 receptor agonist. OUTCOME MEASURES: Primary outomes were changes in glucose-lowering medication cost, HbA1c, and weight. Secondary outcome analyses included the impact to the glucose-lowering medication regimen in terms of dose, number of medications, and number of daily doses or injections. RESULTS: The study population was largely female, aged 55.8 ± 11.7 years, obese, 76% non-Caucasian, equally English and non-English speaking, had a high tablet and injection burden, and had an average baseline HbA1c of 10%. After the addition of a GLP-1 receptor agonist, monthly glucose-lowering medication cost increased $586.86 (overall), $741.69 (oral only baseline regimen), and $530.55 (insulin ± oral baseline regimen) (all P < 0.001). Mean decrease in HbA1c was 1.7% (18 mmol/mol) (P < 0.001) and was similar across all subgroups. Weight decreased overall (-1.8 kg, P < 0.001), and there was a significant shift toward taking fewer oral agents and insulin and fewer daily injections. No statistically significant differences in the primary outcomes were noted in terms of age, gender, English-speaking status, or race. CONCLUSION: Although a positive impact was observed in glycemic control, weight, and reduced polytherapy 6-12 months after initiating a GLP-1 receptor agonist, the increase in monthly glucose-lowering medication cost was significant and may serve as a barrier to treatment.

Pharmacist-managed oral anticoagulation therapy in the community setting.

Pharmacists are at the forefront when caring for patients requiring anticoagulation resulting from chronic conditions, complex medications therapy, or at risk for drug interactions. As a consequence, there is a greater need for pharmacist-managed anticoagulation clinics in the community setting. This article will review special considerations for oral anticoagulant therapy in the elderly, collaborative therapy management, establishment of policies and procedures, documentation of patient visits, patient counseling, and barriers to successful anticoagulation management. It will also discuss evidence-based guidelines for the use of oral anticoagulants and compare the agents currently approved by the Food and Drug Administration. Finally, barriers to anticoagulation management will be examined, including issues with adherence and communication with patients and health care providers.

Patient Perspective: Vaccines for Older People.

Pharmacists, as one of the most accessible health care professionals in the community, can educate, promote, and administer vaccinations. Immunizations are an important way to protect communities from potentially severe diseases, including COVID-19, influenza, pneumonia, shingles, hepatitis, and monkeypox. Though adults 65 years of age and older tend to have higher vaccination rates than other age groups, there are health care disparities that exist in relation to socioeconomic status, race, ethnicity, gender, and sexuality. Vaccine hesitancy and misconceptions cause concerns in older people that can challenge both vaccine administration and rates. Other concerns for older people are the cost, safety, and side effects of vaccines. In addition, updated vaccine guidelines were released by the Centers for Disease Control and Prevention (CDC) in early 2023 that affect recommendations for influenza, COVID-19, and pneumonia vaccines. Older people are at higher risk for severe illness, making immunizations especially important in this patient population. Pharmacists can play a pivotal role in health promotion by staying up to date on immunization guidelines and addressing barriers to vaccination.

The PACE program: home-based long-term care.

Programs of All-Inclusive Care for the Elderly (PACE) provide comprehensive care within the framework of a medical home model for the frail elderly living in the community. Participants must be at least 55 years of age, qualify for nursing facility level of care, and reside safely in the community at the time of enrollment. Often referred to as "nursing homes without walls," PACE programs provide all services covered by Medicare and Medicaid including primary care, medical specialties, adult day health centers, home care, prescription and over-the-counter medications, social work, dietitians, and any other service deemed necessary by the interdisciplinary team. PACE programs offer a multitude of opportunities for pharmacists who specialize in geriatrics, including medication reviews, medication therapy management, therapeutic drug monitoring, fall prevention, quality assurance initiatives, chronic disease management, anticoagulation services, drug information resources, education and inservice programs, medication dispensing and distribution, drug utilization reviews, infection control, and many other services. Senior care pharmacists are uniquely qualified to promote their services to PACE programs and provide quality care to both the interdisciplinary team and participants of the program.

Pharmacists' Impact on Older Adults Transitioning To and From Patient Care Centers: A Scoping Review.

Objective: Expand upon previous reviews conducted on transitions of care (TOC) services with a focus on pharmacist interventions for older adults specifically transitioning to and from long-term care, acute rehabilitation, residential care facilities, care homes, skilled nursing, or assisted living facilities, collectively termed patient care centers (PCC). Data Sources: A PubMed and Ovid MEDLINE search was conducted including citations between 1974 and July 14, 2022. Bibliographies were also reviewed for additional citations. Methods: Articles included described pharmacist interventions during TOC for patients transitioning to and from PCC, were written in English, and reported outcomes pertaining to TOC services. Of 873 citations reviewed, 22 articles met the inclusion criteria. Results: Most studies were prospective in design with small sample sizes, of limited duration, and with varying interventions and reported outcomes. Most explored the transition from hospital to PCC and included a pharmacist intervention involving the identification of medication errors and discrepancies during the TOC. Few studies reported cost savings or 30- and 60-day reductions in readmission rates or mortality. Conclusions: This scoping review revealed a lack of robust clinical trials to assess the effectiveness of specific interventions performed by pharmacists for patients transitioning to and from PCC. Of the available data, pharmacist involvement within an interprofessional team can be an effective intervention to resolve medication discrepancies, reduce readmissions, and medication-related adverse events. An opportunity exists for future studies to explore ways to improve outcomes during TOC within PCC.

Experiential Pharmacy Education During a Pandemic: Lessons Learned.

The COVID-19 pandemic has radically changed how the world operates and introduced a multitude of unprecedented challenges for all health professionals, especially for those responsible for training learners, including pharmacy residents and students. Due to density and social distancing restrictions, many pharmacy schools and residency programs had to transition to virtual experiential learning-with little to no existing literature, structure, or adequate time for planning. This article offers a variety of approaches to ensure that pharmacy learners meet accreditation requirements, engage in interprofessional education and collaboration, reflect on their learning, prioritize self-care, and are adequately prepared to enter geriatric pharmacy practice despite current challenges with the COVID-19 pandemic. Authors address both challenges, as well as opportunities to expand future experiential education for all pharmacy learners.

Nitrofurantoin Use in Frail, Community-Dwelling, Older Adults with Renal Impairment.

Nitrofurantoin is recommended as a first-line antibiotic for the treatment of urinary tract infections (UTIs). However, it is contraindicated in patients with a creatinine clearance (Clcr) less than 60 mL/min. In 2015, the American Geriatrics Society updated the Beers criteria to recommend nitrofurantoin for short-term use in patients with a Clcr greater than or equal to 30 mL/min. It is unknown if nitrofurantoin can be safely and effectively used in a frail patient population with a high incidence of UTIs and frequent use of antibiotics. It is important to have treatment options other than fluoroquinolones and sulfamethoxazole/trimethoprim for patients with recurrent UTIs and frequent antibiotic use to sustain optimal antimicrobial stewardship practices. This study evaluated the safety and efficacy of nitrofurantoin for UTIs in medically complex patients with renal impairment living in a community setting, and it highlights the potential role for pharmacists to encourage antimicrobial stewardship.

Evaluation of vitamin B12 monitoring in patients on metformin in urban ambulatory care settings.

BACKGROUND: Previous studies linked metformin use to vitamin B12 deficiency and demonstrated that the prevalence of vitamin B12 monitoring remains low. OBJECTIVE: This study aimed to assess the occurrence of monitoring vitamin B12 levels in a diverse population. METHODS: This was a retrospective chart review of adult patients with type 2 diabetes on metformin doses ≥ 1000 mg for ≥ 6 months at five Federally Qualified Health Centers (FQHC) and one Program of All-Inclusive Care for the Elderly (PACE). Charts were reviewed for occurrence of monitoring vitamin B12 levels in the past 5 years. Data collected included patient demographics, laboratory data, other potential vitamin B12 level lowering agents, active prescription for vitamin B12 supplementation, concomitant diabetes medications and metformin total daily dose. RESULTS: Of the 322 patients included, 25% had a vitamin B12 level measured in the previous five years. Among the patients with a vitamin B12 level, 87.7% were within the normal range (>350 pg/mL), 11.1% were low (200-300 pg/mL), and only one patient (1.2%) was deficient (<200 pg/mL). These patients were older (69.2 vs. 56.4, p<0.001); more likely to be white (56.8% vs. 37.8%, p=0.04); and more likely to use proton pump inhibitors (34.6% vs. 20.7%, p=0.02) and vitamin B12 supplementation (27.2% vs. 4.6%, p<0.001). Vitamin B12 monitoring differed between the FQHC (15.2%) and PACE (97.4%) sites (p<0.001). Each greater year of age was associated with a 5% increased odds of vitamin B12 monitoring (a OR: 1.05; 95% CI: 1.02-1.08). CONCLUSIONS: The majority of patients seen at the FQHC sites did not have vitamin B12 levels monitored, however, most of the patients who were monitored had normal vitamin B12 levels, which may warrant extending the monitoring time. This finding may also support monitoring patients who have additional risk factors for vitamin B12 deficiency such as concurrent medication use with other vitamin B12 lowering agents or clinical symptoms of deficiency such as peripheral neuropathy. Future studies are needed to determine appropriate frequency of monitoring.

Screening Tool of Older Person's Prescriptions/Screening Tools to Alert Doctors to Right Treatment Medication Criteria Modified for U.S. Nursing Home Setting.

OBJECTIVES: To develop a set of prescribing indicators measurable with available data from electronic nursing home (NH) databases by adapting the European-based 2014 Screening Tool of Older Person's Prescriptions (STOPP) and Screening Tools to Alert Doctors to Right Treatment (START) criteria of potentially inappropriate and underused medications for the U.S. DESIGN: A two-stage expert panel process. In the first stage, the investigator team reviewed 114 criteria for compatibility and measurability. In the second stage, an online modified e-Delphi (OMD) panel was convened to rate the validity of criteria, and two webinars were held to identify criteria with highest relevance to U.S. NHs. PARTICIPANTS: Seventeen experts with recognized reputations in NH care participated in the e-Delphi panel and 12 in the webinar. MEASUREMENTS: Compatibility and measurability were assessed by comparing criteria with U.S. terminology and setting standards and data elements in NH databases. Validity was rated using a 9-point Likert-type scale (1 = not valid at all, 9 = highly valid). Mean, median, interpercentile ranges, and agreement were determined for each criterion score. Relevance was determined by ranking the mean panel ratings on criteria that reached agreement; the webinar participants reviewed and approved half of the criteria with the highest mean values. RESULTS: Fifty-three STOPP/START criteria were deemed to be compatible with the U.S. NH setting and measurable using data from electronic NH databases. E-Delphi panelists rated 48 criteria as valid for U.S. NHs. Twenty-four criteria were deemed to be most relevant, consisting of 22 measures of potentially inappropriate medications and two measures of underused medications. CONCLUSION: This study created the first explicit criteria for assessing the quality of prescribing in U.S. NHs.

Optimizing inhaler use by pharmacist-provided education to community-dwelling elderly.

OBJECTIVE: To assess, using a standard observational tool, the ability of patients to demonstrate and maintain proper inhaled medication administration techniques following pharmacist education. DESIGN: Six-month observational study. SETTING: Patients' homes or adult day health center. PARTICIPANTS: Patients in a Program for All-inclusive Care for the Elderly (PACE) prescribed one or more inhaled medications used at least once daily. INTERVENTION: Instruction by on-site clinical pharmacist. MEASUREMENTS: Hickey's Pharmacies Inhaler Technique assessment (score range: 0-20, higher better). RESULTS: Forty-two patients were evaluated at baseline, taught proper techniques for using inhaled medications, assessed immediately following the education, and re-assessed 4-6 weeks later. The mean pre-assessment score was 14 (SD 4.5, range 0-20), the initial post-assessment score increased to 18 (SD 3, range 10-20). The second post-assessment (4-6 weeks later) score mean was 17.7 (SD 3, range 10-20). Both follow-up scores were significantly improved from baseline (p < 0.05). Multivariable analysis indicated the strongest predictors of second post-training score were: score after initial pharmacist training and being subscribed to auto-refill. These characteristics predicted ∼70% of the variance in the second score (p < 0.001). CONCLUSIONS: These results indicate that education by a pharmacist combined with an auto-refill program can improve and sustain appropriate inhaler use by community-dwelling elders in a PACE program. The improved score was maintained 4-6 weeks later indicating a sustained benefit of medication administration education. Optimal inhaler use ensures optimal dosing and supports appropriate inhaler treatment in lieu of oral agents.