Estimating Tiotropium Wasted Doses After Adding Revefenacin to an Inpatient Formulary: A Single-Center Cross-Sectional Study.

Introduction: Revefenacin is a once-daily nebulized long-acting muscarinic antagonist (LAMA). Revefenacin is supplied as single-use nebulized vials, which may be preferable and less costly for hospital and health-system pharmacies to dispense versus multidose tiotropium inhalers. Estimates of LAMA multidose inhaler wasted doses remains unknown. Methods: This was a single-center descriptive cross-sectional study conducted between January 1 2021 and December 31 2021. Adult patients 18 years and older admitted to a 500-bed academic medical center in the southern United States and were ordered multidose tiotropium packages or single-use revefenacin vials during the study period were included. Results: Among 602 inpatients, there were 705 LAMA orders: 541 tiotropium (76.7%) and 164 revefenacin (23.3%). Four hundred ninety-five tiotropium orders (91.5%) wasted between 20% and 90% of multidose packages. Approximately $24,000 tiotropium doses were wasted versus single-use revefenacin vials. Conclusion: Multidose inhalers of tiotropium dispensed to hospitalized patients contributed to wasted doses compared to nebulized single-use revefenacin vials. Opportunities exist to minimize wasted doses of multidose long-acting inhalers dispensed to hospitalized patients.

Commentary: Is Polyethylene Glycol Toxicity From Intravenous Methocarbamol Fact or Fiction?

Methocarbamol is an antispasmodic muscle relaxant and was the fourth most-prescribed muscle relaxant by volume in the United States in 2021. Intravenous (IV) methocarbamol contains the excipient, polyethylene glycol (PEG), which has been implicated in metabolic acidosis and nephrotoxicity. Intravenous methocarbamol was first approved by the US Food and Drug Administration in 1959 and at that time the IV methocarbamol prescribing information warned of PEG-associated adverse drug events in patients living with renal impairment; however, the manufacturer acknowledged data were lacking to objectively support this claim. Clinicians prescribing and dispensing IV methocarbamol may encounter the warning for PEG-associated metabolic acidosis and nephrotoxicity without knowing the potential risks, or lack thereof, supporting or disavowing this phenomenon. This commentary debates the merits supporting and arguments refuting PEG-associated metabolic acidosis and nephrotoxicity in patients treated with IV methocarbamol.

Which patients with COPD need an inhaled corticosteroid?

ABSTRACT: Inhaled bronchodilators are recommended to treat patients with any category of chronic obstructive pulmonary disease (COPD). Clinical practice guidelines conditionally recommend inhaled corticosteroids (ICS) for patients with eosinophilic COPD phenotypes, patients who experience hospitalizations for or frequent severe exacerbations of COPD, and patients with comorbid asthma. This article outlines which patients with COPD may benefit from an ICS.

Inhaled Medication Errors During Hospitalization or on Hospital Discharge in Patients Living With Chronic Obstructive Pulmonary Disease: A Literature Review.

Inhaled medications, including beta-agonists, muscarinic antagonists, and corticosteroids, are the backbone of chronic obstructive pulmonary disease (COPD) treatment, and pharmacotherapy plans are frequently optimized during and following hospitalization. Clinical practice guidelines acknowledge that patients living with COPD may experience medication errors from inadequate inhaler technique or device faults, but inhaled medication errors within COPD pharmacotherapy plans remain unreported. This literature review aimed to collect and present studies describing medication errors occurring with inhaled medications in patients living with COPD during and following hospitalization. The databases searched included Ovid MEDLINE, Embase, and International Pharmaceutical Abstracts. One hundred forty-five unique studies were collected, and 10 studies were included. The rate of inhaled medication errors reported across the 10 studies ranged between 2.5% and 66% of patients living with COPD and who were hospitalized or discharged. The incidence and types of medication errors reported across the studies varied significantly. Standardization in categorizing and reporting inhaled medication errors is necessary for future studies to determine the true incidence of inhaled medication errors occurring in patients living with COPD who are hospitalized or discharged.

Theophylline for the management of respiratory disorders in adults in the 21st century: A scoping review from the American College of Clinical Pharmacy Pulmonary Practice and Research Network.

Theophylline is an oral methylxanthine bronchodilator recommended as alternate therapy for the treatment of asthma and chronic obstructive pulmonary disease (COPD). However, it is not generally recommended for the treatment of other respiratory disorders such as obstructive sleep apnea (OSA) or hypoxia. Most clinical practice guidelines rely on evidence published prior to the year 2000 to make these recommendations. This scoping review aimed to gather and characterize evidence describing theophylline for the management of respiratory disorders in adults between January 1, 2000 and December 31, 2020. Databases searched included Ovid MEDLINE, Embase, CINAHL Complete, Scopus, and International Pharmaceutical Abstracts. This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping reviews. Studies were included if they were published in English, theophylline was used for any respiratory disorder, and the study outcomes were disease- or patient-oriented. After removal of duplicates, 841 studies were screened and 55 studies were included. Results aligned with current clinical guideline recommendations relegating theophylline as an alternative therapy for the treatment of respiratory disorders, in favor of inhaled corticosteroids and inhaled bronchodilators. This scoping review identified the need for future research including: theophylline versus other medications deemed alternative therapies for asthma and COPD, meta-analyses of low-dose theophylline, and studies evaluating evidence-based patient-oriented outcomes for OSA, hypoxia, ventilator-induced diaphragmatic dysfunction, and spinal cord injury-related pulmonary function.

Evaluation of Naloxone Co-Prescribing Rates for Older Adults Receiving Opioids via a Meds-to-Beds Program.

Over 10,000 older adults died from opioid overdose in 2019. Naloxone is an underutilized antidote that could prevent many opioid overdose-related deaths. There is a paucity of literature evaluating naloxone prescribing through meds-to-beds programs and in older adults. This single-center, retrospective, observational cohort study aimed to assess prescribing patterns of naloxone in patients 65 years and older who were prescribed opioids via a meds-to-beds program between December 2020 and November 2021. All patients 65 years and older dispensed an opioid via meds-to-beds were included. Patients receiving hospice or comfort care or those with unavailable records were excluded. The primary outcome was to assess the frequency of naloxone co-prescribing with opioid prescriptions via meds-to-beds. The 144 patients included were primarily females with a median age of 69 years old and opioid prescriptions for 45 morphine milligram equivalents daily. Two patients were prescribed naloxone (1.4%), one of whom was ultimately dispensed naloxone (0.7%). Of the 65 prescribers included in our study, the incidence of naloxone co-prescribing (2/65, 3.1%) was no different from a previously-reported rate among prescribers (3/179, 1.7%), p = 0.61. Naloxone co-prescribing for older adults receiving opioid prescriptions through a meds-to-beds program was low and opportunities for program enhancement exist.

Relationships Between Remote Asynchronous Lectures and Summative Assessment Performance in four Pharmacotherapeutics Courses.

Background: Synchronous education describes when teaching, learning, and assessment occur concurrently and asynchronous education describes when teaching, learning, and assessment occur anytime. Remote learning is where teaching and learning occur via technological means. Objective: This report describes a remote, asynchronous learning method implemented in a 3-year, block curriculum, Doctor of Pharmacy degree program. Methods: Remote asynchronous lectures embedded with quizzes were delivered to pharmacy students at the end of their first professional year and beginning of their second professional year. Camtasia software and Screencast.com were utilized during portions of 4 pharmacotherapeutic-based courses. Students completed time-spaced quizzes embedded every 5 to 15 minutes throughout the videos and quiz scores were recorded. Discrete watches, number of total watches, and average number of video quiz questions correctly answered were examined for Spearman's rank correlation coefficient (ρ) with end-of-course summative assessment scores. Results: There were no strong positive correlations between discrete watches, number of total watches, and average number of video quiz questions correctly answered and end-of-course assessment scores (ρ range: -0.47 to 0.25). There were weak to moderate correlations within the rheumatology and dermatology assessment scores based on the Screencast.com content questions and the number of unique video watches (ρ = 0.40), average number of total video watches (ρ = 0.28), and average percent of quiz questions correct (ρ = 0.40), all of which were statistically significant (P < 0.05). Conclusions: Remote asynchronous lectures including time-spaced quizzes were not associated with improvements in summative assessment performance. Mild positive correlations between remote asynchronous lectures and time-spaced quizzes may correspond with discrete questions on a summative assessment but those relationships may be influenced by the content within the remote asynchronous lectures.

A systematic review of the drug-drug interaction between statins and colchicine: Patient characteristics, etiologies, and clinical management strategies.

Colchicine and statins are frequently co-prescribed for prevention and treatment of cardiovascular diseases, auto-inflammatory diseases, and gout. Both are substrates and inhibitors of the cytochrome P-450 (CYP) 3A4 isozyme and P-glycoprotein so that taken together, they represent a clinically significant interaction. Data suggest the interaction may be associated with potentially life-threatening myopathies and rhabdomyolysis. The purposes of this systematic review (SR) were to gather and appraise evidence surrounding the statin-colchicine drug interaction and discuss related risk-mitigation strategies. An electronic literature search was performed. Twenty-one articles met the protocol to be included in the qualitative analysis: 18 case reports/series, 2 retrospective observational cohort studies, and 1 retrospective case-control study. Thirty-eight patients developed an adverse drug event (ADE) receiving statin-colchicine combination therapy; 25 (66%) patients developed myopathy; 10 (26%) patients developed rhabdomyolysis, and three (8%) patients developed neuromyopathy. Over 70% of patients developed ADEs on simvastatin or atorvastatin, and 80% of studies reported moderate-to-high intensity statins. Colchicine dosing varied but ranged between 0.5 to 1.5 mg daily. Sixty-two percent of patients in the case reports/series had comorbid renal disease. Seven studies (33% of all included studies) reported patients taking concomitant interacting medications at the CYP3A4 and/or P-glycoprotein efflux pump. Seventeen studies (81% of all included studies) reported ADEs leading to hospitalization. A multivariate analysis from one case-control study identified risk factors prognosticating myopathy ADEs in patients taking statin-colchicine therapy: comorbid renal disease and/or cirrhosis, colchicine doses 1.2 mg daily or greater, and concomitant interacting medications. Clinicians must be cognizant that the statin-colchicine drug interaction may lead to patient harm and thus should employ risk-mitigation strategies for statin-associated muscle symptoms. Future studies are warranted to validate clinically relevant risk factors that are strongly associated with the complications owing to the statin-colchicine drug interaction.

A nonthrombotic pulmonary embolus caused by polyalkylimide dermal filler: A case report and literature review of medication management.

BACKGROUND: This report presents the case of a patient who developed a nonthrombotic embolus attributed to a polyalkylimide dermal filler, and it also charts pharmacotherapeutic strategies for polyalkylimide complications reported in the literature. CASE SUMMARY: A 31-year-old female presented to a community teaching hospital with dyspnea, hemoptysis, and fever. A thorough history revealed that the patient received intragluteal injections of a polyalkylimide dermal filler (Bio-Alcamid) 4 days before hospitalization, although it was initially and incorrectly diagnosed as silicone embolism syndrome. High-dose intravenous steroids and antibiotics were ineffective, and the patient was transferred to a higher level of care for surgical management. Therein, the patient developed additional complications, including multiple thromboembolic events and the need for long-term enteral nutrition. After a 63-day stay in the intensive care unit and a 13-day stay in an inpatient postacute facility, the patient's postdischarge care transitions included 3 subsequent emergency department visits related to enteral feeding tube malfunction. PRACTICE IMPLICATIONS: Polyalkylimide is a hydrogel polymer derived from acrylic acid that is used as a dermal filler. Postinjection complications include dermal filler migration and abscess formation. Surgical resection of the filler and prophylactic antibiotics have, anecdotally, been used with success. Comparatively, silicone dermal filler complications may be treated with high-dose intravenous corticosteroids. Although silicone and polyalkylimide are both classified as permanent dermal fillers, the management of their complications differs, especially with regard to medications. This case underscores the necessity for clinicians to accurately identify the type of dermal filler used in order to recommend effective medication management to treat complications. Unlike silicone dermal filler treatment, corticosteroids may actually exacerbate polyalkylimide dermal filler complications. Beta-lactam antibiotics for at least 14 days may be reasonable to treat the cutaneous infectious complications arising from polyalkylimide dermal filler use.

Netarsudil for the Treatment of Open-Angle Glaucoma and Ocular Hypertension: A Literature Review.

OBJECTIVE: To evaluate netarsudil's role as first-line therapy for the treatment of open-angle glaucoma (OAG) and ocular hypertension (OHT). DATA SOURCES: A literature search utilizing MEDLINE and CINAHL was performed using netarsudil and AR-13324 as keywords. Studies published from January 1970 to September 2020 were eligible. STUDY SELECTION AND DATA EXTRACTION: For inclusion, articles were required to be published in English and participants enrolled in phase I, II, or III clinical trials. Articles were excluded if netarsudil was coformulated with another medication. Preclinical research, case reports, case series, review articles, citations without an abstract, and newsletters were excluded. LITERATURE REVIEW: The search retrieved 97 unique citations; 90 results were excluded, and 7 studies were included for analysis. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE: In all, 20 years elapsed between the Food and Drug Administration's approvals of distinct medications to treat OAG. Existing first-line therapies target the uveoscleral pathway, which is responsible for a small amount of aqueous humor outflow. Rho kinase inhibitors target the trabecular pathway, which is responsible for 90% of aqueous humor outflow; thus, Rho kinase inhibitors may significantly reduce intraocular pressure and improve clinical outcomes for patients with OAG or OHT. CONCLUSIONS: Evidence demonstrates that netarsudil is inferior to prostaglandin analogues and noninferior to topical ß-blockers in the treatment of OAG and OHT. Hyperemia is a common adverse drug reaction, which often resolves after medication discontinuation. Additional phase III clinical trials and evidence-based guidelines are necessary to determine netarsudil's position in OAG and OHT management.

Integration of Latin American Complementary and Alternative Medicine Topics Into a Doctor of Pharmacy Curriculum and Survey of Student Attitudes and Behaviors.

One in 3 adults report using complementary and alternative medicine (CAM) and as many as 7 in 10 Hispanic patients report CAM use. Pharmacists often encounter patients who use CAM products and therefore college of pharmacy curricular standards require both CAM and cultural competence training; however, there is little guidance for colleges on how to best deliver this material. In Fall 2017, Larkin University College of Pharmacy implemented a curricular change wherein first professional (P1) year pharmacy students selected, researched, and presented on a CAM product from Latin America. Pre-post surveys were administered to the students to measure their attitudes and behaviors toward CAM before and after completing their project. Survey results showed that student attitudes and behaviors toward CAM were largely unchanged; however, post-survey results showed that students agreed that they knew where to search for Latin American CAM information (P < 0.05). Integration of Latin American CAM topics was successfully implemented in the P1 year of a Doctor of Pharmacy degree curriculum to foster cultural competence.

Development and Implementation of Interprofessional Relations Between a College of Pharmacy and Osteopathic Residency Programs in a Community Teaching Hospital.

Background: Team-based health care optimizes patient outcomes, and therefore, both interprofessional education (IPE) and interprofessional relations (IPR) are required in health professions education, postgraduate training, and real-world clinical practice. Existing literature describes progressive developments and assessments of IPE in colleges of pharmacy and medicine; however, there are fewer reports describing processes or projects that foster physician-pharmacist IPR in clinical practices without established interprofessional collaborations. Objectives: The primary objective was to establish IPR between pharmacists and osteopathic residents in a community teaching hospital. The secondary objective was to innovate the delivery of pharmacotherapeutic content delivered to the residents during their didactic lecture series by providing active learning strategies. Methods: This report describes a project wherein college of pharmacy faculty developed IPR with osteopathic residents in a community teaching hospital that previously did not have any established physician-pharmacist IPR. Osteopathic medical residents completed a post-implementation survey after they attended a 12-month series of didactic lectures that incorporated active learning delivered by pharmacist faculty. Results: Sixty-six residents were eligible to complete the survey; 20 residents completed the survey. Eighteen residents believed that both physicians and pharmacists should be educated to establish IPR and that it should be included in professional, graduate, and continuing education settings for both professions. Sixteen residents believed that the active learning techniques employed by college of pharmacy faculty were useful for IPR. Conclusions: Physician-pharmacist IPR may be achievable in settings where IPR was previously sparse. Shared interests, adherence, and innovations in IPR frameworks are essential for developing physician-pharmacist IPR.

Upper Gastrointestinal Bleeding in a Male Patient Taking Megestrol Acetate and Rivaroxaban: A Case Report.

OBJECTIVE: This report describes the case of a 76-year-old male who developed an upper gastrointestinal bleed shortly after beginning megestrol acetate (MGA) to treat geriatric failure to thrive (GFTT). He was also taking rivaroxaban for stroke prevention because of atrial fibrillation but had a low risk of bleeding. This article aims to provide the reader with an overview of MGA's impact on hemostasis, as well as a review of therapeutics on appetite stimulants and important transitions of care considerations for GFTT.
SETTING: The primary setting was a community teaching hospital in Florida. The patient had many transitions of care, including hospital-to-skilled nursing facility and then a hospital readmission for the primary problem reported here. A skilled nursing facility medication administration record and outpatient community pharmacy were the primary sources of the patient's admission and discharge medication histories.
PRACTICE CONSIDERATIONS: MGA's published labeling supports a prothrombotic mechanism; however, its pharmacology may also confer anticoagulant properties. This may lead to potential drug-drug interactions in patients on concomitant anticoagulant therapy. There is weak evidence supporting appetite stimulants in GFTT, and transitions of care in this population is especially important because of these patients' frequent care continuum contact.
CONCLUSIONS: MGA, a synthetic derivative of endogenous progesterone used to treat GFTT, may exert either prothrombotic or anticoagulant effects, and as such potential for drug interactions with anticoagulants must be considered. Patients taking MGA should be closely monitored for coagulation changes throughout transitions of care.

Post-graduate year two transitions of care pharmacy residencies no longer accredited.

INTRODUCTION: Literature supports pharmacist integration within transitions of care. A total of eight health-system pharmacies and colleges of pharmacy developed focused post-graduate year two (PGY2) training in this specialty. However, in fall 2016, ongoing accreditation of these PGY2 transitions of care programs was discontinued by the American Society of Health-System Pharmacists Commission on Credentialing. PERSPECTIVE: Healthcare relies on interprofessional collaborations and corresponding programs in order to improve patient care. Pharmacists who have completed specialized training in transitions of care are not only leaders in this realm but also ambassadors for interprofessional medicine. IMPLICATIONS: Rebranding transitions of care PGY2 programs fails to capture all the opportunities available to train and mentor new transitions of care pharmacists. Lack of consensual accreditation introduces variability within training. There may be opportunities to revisit transitions of care PGY2 accreditation in the future.