Naloxone access in perinatal substance use disorder.

BACKGROUND: Risk of fatal drug overdose is higher in pregnant and postpartum people with substance use disorder (SUD) than for nonpregnant women of reproductive age. It is recommended that naloxone is prescribed for pregnancies complicated by opioid or stimulant use disorder. OBJECTIVE: The purpose of this study was to assess the rates of naloxone coprescribing with buprenorphine in a perinatal SUD (PSUD) specialty clinic and identify opportunities for pharmacist-led interventions to improve communication and documentation surrounding naloxone access to achieve a rate of 100% coprescribing of naloxone with buprenorphine. PRACTICE DESCRIPTION: A clinical pharmacist practitioner is embedded on the Project CARA (Care that Advocates Respect/Resilience/Recovery for All) team, which provides outpatient SUD care integrated with perinatal care in Western North Carolina. PRACTICE INNOVATION: The clinical pharmacist practitioner assessed baseline rates of naloxone coprescribing with medications for opioid use disorder. Interventions to improve rates of coprescribing include provider education, electronic health record (EHR) documentation templates, and direct patient outreach. EVALUATION METHODS: Baseline rates of naloxone coprescribing were assessed and then re-evaluated after different interventions to measure pharmacist impact. RESULTS: Each intervention improved rates of naloxone coprescribing in a PSUD clinic. EHR documentation templates had the largest impact on baseline efforts, although the long-term benefits derived from these efforts have not yet been demonstrated. Substantial time investment from the pharmacist was required to address patients' barriers to obtaining naloxone after their visits. CONCLUSION: Further process improvement should address barriers to naloxone access for both patients and providers. This may include proactive identification of patients in need of naloxone and a "meds-to-beds" pilot to assist patients in navigating logistical challenges.

Association of Pharmacogenomic Phenotypes in CYP2D6, CYP2C9, CYP2C19, and CYP3A5 on Polypharmacy in Veterans.

The Department of Veterans Affairs (VA) utilizes a pharmacogenomic (PGx) program that analyzes specific "pharmacogenes." This study evaluates the effect that pharmacogenes may have on prevalence of polypharmacy. This retrospective cohort study included patients with VA prescriptions who underwent PGx testing. We quantified prescriptions active or recently expired at the time of PGx testing. We constructed two co-primary polypharmacy (≥10 medications) end points: (i) based on all medications and (ii) requiring that at least one medication was affected by a pharmacogene of interest. Pharmacogenes and actionable phenotypes of interest included poor and ultrarapid metabolizers for CYP2D6, CYP2C9, and CYP2C19 and intermediate and normal metabolizers for CYP3A5. Patients were classified as having 0, 1, and 2+ total phenotypes across all genes. Of the 15,144 patients screened, 13,116 met eligibility criteria. Across phenotype cohorts, there was no significant association with polypharmacy using all medications, number of total medications, or number of medications affected by phenotypes. However, there was a significant difference in patients with polypharmacy prescribed ≥1 medication impacted by PGx across phenotype groups: 2,514/4,949 (51%), 1,349/2,595 (52%), 204/350 (58%) (P = 0.03, OR 1.31, 95% CI 1.02-1.67). The median number of medications affected by PGx phenotypes with ≥1 PGx-impacted medication across phenotype groups was a median of 0 (IQR 0, 0), 0 (IQR 0, 0), and 1 (IQR 0, 1) (P < 0.001). In patients prescribed ≥1 medication impacted by PGx, those with more actionable pharmacogenomic phenotypes were more likely to meet polypharmacy criteria.

Application of Integrated Drug Screening/Kinome Analysis to Identify Inhibitors of Gemcitabine-Resistant Pancreatic Cancer Cell Growth.

Continuous exposure of a pancreatic cancer cell line MIA PaCa-2 (MiaS) to gemcitabine resulted in the formation of a gemcitabine-resistant subline (MiaR). In an effort to discover kinase inhibitors that inhibited MiaR growth, MiaR cells were exposed to kinase inhibitors (PKIS-1 library) in a 384-well screening format. Three compounds (UNC10112721A, UNC10112652A, and UNC10112793A) were identified that inhibited the growth of MiaR cells by more than 50% (at 50 nM). Two compounds (UNC10112721A and UNC10112652A) were classified as cyclin-dependent kinase (CDK) inhibitors, whereas UNC10112793A was reported to be a PLK inhibitor. Dose-response experiments supported the efficacy of these compounds to inhibit growth and increase apoptosis in 2D cultures of these cells. However, only UNC10112721A significantly inhibited the growth of 3D spheroids composed of MiaR cells and GFP-tagged cancer-associated fibroblasts. Multiplexed inhibitor bead (MIB)-mass spectrometry (MS) kinome competition experiments identified CDK9, CLK1-4, DYRK1A, and CSNK1 as major kinase targets for UNC10112721A in MiaR cells. Another CDK9 inhibitor (CDK-IN-2) replicated the growth inhibitory effects of UNC10112721A, whereas inhibitors against the CLK, DYRK, or CSNK1 kinases had no effect. In summary, these studies describe a coordinated approach to discover novel kinase inhibitors, evaluate their efficacy in 3D models, and define their specificity against the kinome.