Integrating real-world skills and diabetes lifestyle coach training into a revised health promotion and communications course.

BACKGROUND AND PURPOSE: Effective communication skills are essential for all pharmacists, regardless of practice setting. An implicit need in pharmacy education is to emphasize direct application of these skills to future healthcare practice prior to experiential rotations. The aim of this article is to describe how we revised a required first professional year (P1) doctor of pharmacy course to achieve two main goals: 1) improve the course relevance by connecting content to real-world skills; and 2) qualify all pharmacy students at our institution as certified National Diabetes Prevention Program (DPP) lifestyle coaches upon course completion. EDUCATIONAL ACTIVITY AND SETTING: Lifestyle coach training approved by the Centers for Disease Control and Prevention (CDC) was integrated into a P1 communications course consisting of 14 modules that include: review of diabetes pathophysiology, group facilitation skills, social determinants of health, food tracking, action planning, participant retention and program administration. This content serves as a direct application of pre-existing course objectives related to knowledge (evidence-based theory) and skills (technical and counseling) required for effective communication with patients, families, and health professionals. FINDINGS: Between 2019 and 2022, the redesigned course was offered to 373 P1 students. Course evaluations during this time were consistently positive. The average evaluation score since DPP activities were integrated into the course was 3.41 (on a 4-point scale). Based upon course evaluations, students appreciated three main benefits of incorporating lifestyle coach certification into the pharmacy curriculum: 1) a certified skill that can differentiate them in the job market; 2) practice of skills on real patients under faculty supervision in the community setting; 3) early exposure to pharmacy patient care topics, thus contributing to professional identity. SUMMARY: Integration of lifestyle coach training into an existing core P1 pharmacy course increased application and assessment of communications skills and allowed wider availability of trained coaches to deliver DPP in the community.

Job satisfaction among board-certified pharmacists in Virginia.

BACKGROUND: Board certification has been associated with job satisfaction. Identifying factors influencing board-certified pharmacists' job satisfaction can assist employers in recruitment and retention. OBJECTIVES: To identify factors associated with job satisfaction among board-certified pharmacists in Virginia. METHODS: This cross-sectional study utilized data from the 2018 Virginia Pharmacy Workforce Survey and included pharmacists who held an active license in Virginia, were employed within the last year, and held any Board of Pharmacy Specialties certification. Descriptive statistics were used to summarize the data, and bivariate analyses compared job satisfaction across demographics and practice characteristics. Multivariable logistic regression identified factors associated with job satisfaction. RESULTS: Of 15,424 licensed pharmacists, 13,962 completed the survey (90.5%), while 1,284 (9.2%) met the inclusion criteria. Respondents were primarily female (69.4%) with a mean (SD) of 10.5 (9.6) years of work experience. Pharmacists predominantly held one full-time position (81.5%), earned an annual income between $100,000-$149,999 (77.0%), and worked in inpatient health systems (43.9%). Most board-certified pharmacists (93.7%) reported being very/somewhat satisfied with their current job. Job satisfaction was associated with work setting, primary hours worked per week, and paid sick leave benefits in bivariate analyses. In the multivariable logistic regression model, pharmacists working 30-49 versus ≥50 h/wk in their primary job (aOR= 2.91, 95% CI 1.63, 5.20), earning ≥$150,000 versus $100,000-$149,999 (aOR=4.60, 95% CI 1.21, 17.46), and with paid sick leave benefits (aOR= 1.92, 95% CI 1.19, 3.10) were more likely to report higher job satisfaction. Additionally, working in academia (aOR= 5.36, 95% CI 1.45, 19.85), inpatient health system (aOR= 3.13, 95% CI 1.41, 6.94), and outpatient health system (aOR= 4.07, 95% CI 1.33, 12.51) were associated with job satisfaction. CONCLUSION: Board-certified pharmacists in Virginia reported high job satisfaction. Primary hours worked per week, income, paid sick leave, and work setting were positively associated with job satisfaction.

Role of lipoprotein(a) in atherosclerotic cardiovascular disease: A review of current and emerging therapies.

Lipoprotein(a), or Lp(a), is structurally like low-density lipoprotein (LDL) but differs in that it contains glycoprotein apolipoprotein(a) [apo(a)]. Due to its prothrombotic and proinflammatory properties, Lp(a) is an independent risk factor for atherosclerotic cardiovascular disease (ASCVD) and aortic valve stenosis. Lp(a) levels are genetically determined, and it is estimated that 20%-25% of the global population has an Lp(a) level ≥50 mg/dL (or ≥125 nmol/L). Diet and lifestyle interventions have little to no effect on Lp(a) levels. Lipoprotein apheresis is the only approved treatment for elevated Lp(a) but is time-intensive for the patient and only modestly effective. Pharmacological approaches to reduce Lp(a) levels and its associated risks are of significant interest; however, currently available lipid-lowering therapies have limited effectiveness in reducing Lp(a) levels. Although statins are first-line agents to reduce LDL cholesterol levels, they modestly increase Lp(a) levels and have not been shown to change Lp(a)-mediated ASCVD risk. Alirocumab, evolocumab, and inclisiran reduce Lp(a) levels by 20-25%, yet the clinical implications of this reduction for Lp(a)-mediated ASCVD risk are uncertain. Niacin also lowers Lp(a) levels; however, its effectiveness in mitigating Lp(a)-mediated ASCVD risk remains unclear, and its side effects have limited its utilization. Recommendations for when to screen and how to manage individuals with elevated Lp(a) vary widely between national and international guidelines and scientific statements. Three investigational compounds targeting Lp(a), including small interfering RNA (siRNA) agents (olpasiran, SLN360) and an antisense oligonucleotide (pelacarsen), are in various stages of development. These compounds block the translation of messenger RNA (mRNA) into apo(a), a key structural component of Lp(a), thereby substantially reducing Lp(a) synthesis in the liver. The purpose of this review is to describe current recommendations for screening and managing elevated Lp(a), describe the effects of currently available lipid-lowering therapies on Lp(a) levels, and provide insight into emerging therapies targeting Lp(a).

Survey of CDC-recognized community pharmacies providing the National Diabetes Prevention Program and impact of the COVID-19 pandemic on program delivery.

BACKGROUND: The Centers for Disease Control and Prevention (CDC) established the National Diabetes Prevention Program (NDPP) to prevent type 2 diabetes using an evidence-based lifestyle intervention program provided by community- and health care-based organizations, including community pharmacies. OBJECTIVES: This study aimed to characterize CDC-recognized community pharmacies offering NDPP and determine the impact of the coronavirus disease 2019 (COVID-19) pandemic on program delivery. METHODS: A list of CDC-recognized community pharmacies offering NDPP was obtained from the CDC Registry of Recognized Programs on September 19, 2020. A 23-question cross-sectional survey was created to obtain information about program inception, delivery, recruitment, enrollment, program evaluation, reimbursement, and the impact of the COVID-19 pandemic. Each pharmacy was contacted via telephone using a standardized script and invited to complete the survey over the phone or online. A follow-up e-mail was then sent approximately 2 weeks later to pharmacies that had not responded. RESULTS: A total of 73 community pharmacies were identified in the CDC registry. Of the 64 eligible community pharmacies, 42% (n = 27) completed the survey. Most community pharmacies offering NDPP were in the Southeastern (41%) and Midwestern (22%) regions of the United States. A majority were independent pharmacies (78%) and had "pending" CDC recognition status (74%). Program delivery primarily occurred in the pharmacy (48%) or in a hybrid model (26%). Most programs were not submitting reimbursement claims (74%) and did not charge participants (82%). Nearly two-thirds of pharmacies (63%) strongly agreed that COVID-19 had significantly affected their programs, yet most (67%) continued to offer NDPP during the pandemic. CONCLUSION: To our knowledge, this is the first characterization of CDC-recognized community pharmacies providing NDPP. Best practices for implementing NDPP at community pharmacies warrant further exploration and models to ensure long-term sustainability. COVID-19 affected most community pharmacies providing NDPP, but the majority continued to offer NDPP during the pandemic.

The cost-effectiveness of pharmacist-physician collaborative care models vs usual care on time in target systolic blood pressure range in patients with hypertension: a payer perspective.

BACKGROUND: Hypertension is highly prevalent in the United States, affecting nearly half of all adults (43%). Studies have shown that pharmacist-physician collaborative care models (PPCCMs) for hypertension management significantly improve blood pressure (BP) control rates and provide consistent control of BP. Time in target range (TTR) for systolic BP is a novel measure of BP control consistency that is independently associated with decreased cardiovascular risk. There is no evidence that observed improvement in TTR for systolic BP with a PPCCM is cost-effective. OBJECTIVE: To compare the cost-effectiveness of a PPCCM with usual care for the management of hypertension from the payer perspective. METHODS: We used a decision analytic model with a 3-year time horizon based on published literature and publicly available data. The population consisted of adult patients who had a previous diagnosis of high BP (defined as office-based BP ≥ 140/90 mmHg) or were receiving antihypertensive medications. Effectiveness data were drawn from 2 published studies evaluating the effect of PPCCMs (vs usual care) on TTR for systolic BP and the impact of TTR for systolic BP on 4 cardiovascular outcomes (nonfatal myocardial infarction [MI], stroke, heart failure [HF], and cardiovascular disease [CVD] death). The model incorporated direct medical costs, including both programmatic costs (ie, direct costs for provider time) and downstream health care utilization associated with acute cardiovascular events. One-way sensitivity and threshold analyses examined model robustness. RESULTS: In base-case analyses, PPCCM hypertension management was associated with lower downstream medical expenditures (difference: -$162.86) and lower total program costs (difference: -$108.00) when compared with usual care. PPCCM was associated with lower downstream medical expenditures across all parameter ranges tested in the deterministic sensitivity analysis. For every 10,000 hypertension patients managed with PPCCM vs usual care over a 3-year time horizon, approximately 27 CVD deaths, 29 strokes, 21 nonfatal MIs, and 12 incident HF diagnoses are expected to be averted. CONCLUSIONS: This is the first study to evaluate the cost-effectiveness of PPCCM compared to usual care on TTR for systolic BP in adults with hypertension. PPCCM was less costly to administer and resulted in downstream health care savings and fewer acute cardiovascular events relative to usual care. Although further research is needed to evaluate the long-term costs and outcomes of PPCCM, payer coverage of PPCCM services may prevent future health care costs and improve patient cardiovascular outcomes. DISCLOSURES: No funding was received for the completion of this research. The authors have nothing to disclose. Study results were presented as an abstract at the AMCP 2021 Virtual, April 12-16, 2021.

An ounce of prevention is worth a pound of cure: considerations for pharmacists delivering the National Diabetes Prevention Program.

Prediabetes is highly prevalent in the United States affecting over 88 million adults. In 2010, the Centers for Disease Control and Prevention (CDC) established the National Diabetes Prevention Program (NDPP), an intensive lifestyle program consisting of a 16-lesson curriculum focused on diet, exercise, and behavior modification, with the ultimate goal to reduce progression from prediabetes to diabetes. Despite tens of millions of adults potentially qualifying to participate in the program, the uptake of the NDPP has been exceedingly low. As a result, the CDC has focused its efforts on engaging with local health departments and community partners, including community pharmacies, across the United States to scale-up enrollment in the NDPP. In this commentary we discuss factors affecting implementation of the NDPP in community pharmacies and other settings where pharmacists practice, including training, space, personnel, recruitment and enrollment, retention, and sustainability.

An ounce of prevention is worth a pound of cure: considerations for pharmacists delivering the National Diabetes Prevention Program

Prediabetes is highly prevalent in the United States affecting over 88 million adults. In 2010, the Centers for Disease Control and Prevention (CDC) established the National Diabetes Prevention Program (NDPP), an intensive lifestyle program consisting of a 16-lesson curriculum focused on diet, exercise, and behavior modification, with the ultimate goal to reduce progression from prediabetes to diabetes. Despite tens of millions of adults potentially qualifying to participate in the program, the uptake of the NDPP has been exceedingly low. As a result, the CDC has focused its efforts on engaging with local health departments and community partners, including community pharmacies, across the United States to scale-up enrollment in the NDPP. In this commentary we discuss factors affecting implementation of the NDPP in community pharmacies and other settings where pharmacists practice, including training, space, personnel, recruitment and enrollment, retention, and sustainability (AU)

Oral Semaglutide: A Review of the First Oral Glucagon-Like Peptide 1 Receptor Agonist.

Glucagon-like peptide 1 receptor agonists (GLP-1 RAs) are highly effective at lowering hemoglobin A1c (HbA1c) and facilitating weight loss. Four agents in the GLP-1 RA class, albiglutide, liraglutide, dulaglutide, and semaglutide, also have cardioprotective effects. However, subcutaneous administration of these agents remains a major reason for their underutilization. A new coformulation of semaglutide with sodium N-[8-(2-hydroxybenzoyl) amino caprylate (SNAC) is the first oral GLP-1 RA reviewed by the U.S. Food and Drug Administration (FDA). The SNAC technology prevents destruction of semaglutide in the stomach and facilitates transcellular absorption through the gastric membrane enabling semaglutide to reach systemic circulation intact. The oral formulation of semaglutide was studied in the PIONEER trials, demonstrating similar efficacy to the presently available GLP-1 RAs with regard to HbA1c lowering and weight loss. Although the PIONEER 6 trial suggests positive effects on cardiovascular mortality with oral semaglutide, these benefits may not fully be appreciated until the completion of the SOUL trial.

Combination therapy with once-weekly glucagon like peptide-1 receptor agonists and dipeptidyl peptidase-4 inhibitors in type 2 diabetes: a case series

BACKGROUND: National treatment guidelines recommend glucagon-like peptide receptor agonists (GLP-1 RAs) as add-on therapy to oral agents. However, GLP-1 RAs in combination with dipeptidyl peptidase-4 (DPP-4) inhibitors is not recommended due to a lack of evidence. OBJECTIVE: This case series aims to describe the efficacy and safety of once-weekly GLP-1 RAs administered concomitantly with DPP-4 inhibitors in patients with type 2 diabetes. METHODS: A retrospective chart review of electronic medical records at a free health clinic was conducted between July 2014 and September 2016. Patients 18 years and older with type 2 diabetes were included if they received concomitant DPP-4 inhibitor and once-weekly GLP-1 RA therapy with at least one glycated hemoglobin A1c (HbA1c) measurement within three to six months of starting the combination. The primary and secondary outcomes included change in HbA1c and weight, and patient reported adverse events. RESULTS: Out of forty-three patients that received combination DPP-4 inhibitor plus GLP-1 RA therapy, only eighteen received once-weekly GLP-1 RA. At 3 months, the median (IQR) HbA1c and weight change was -0.8% (-4.3 to 2%) and -0.4kg (-4.2 to 5.8 kg) respectively. No patients reached an HbA1c below 7% and only three patients (17%) reached a HbA1c less than 8%. Patient reported adverse effects included gastrointestinal disturbances (28%), hypoglycemic symptoms (17%), and injection site reactions (0.6%). CONCLUSIONS: Concomitant use of once-weekly GLP-1 RAs and DPP-4 inhibitors provides only modest improvement in glycemic control with minimal weight loss benefits, which is similar to monotherapy with either agent. The combination is unlikely to provide synergistic effects and is not cost effective. These data support the current recommendations against use of combined incretin therapy

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Recent Updates on the Use of PCSK9 Inhibitors in Patients with Atherosclerotic Cardiovascular Disease.

PURPOSE OF REVIEW: Atherosclerotic cardiovascular disease (ASCVD) is caused by elevated levels of low-density lipoprotein cholesterol (LDL-C). Although statins significantly reduce ASCVD risk, there remains a high degree of residual risk in statin-treated patients. Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibition has emerged as a significant therapeutic target for further lowering of LDL-C when used in combination with statins. The purpose of this review is to provide an update on recent evidence supporting the use of PCSK9 inhibitors in patients with ASCVD. RECENT FINDINGS: Alirocumab and evolocumab were approved by the US Food and Drug Administration in 2015. Multiple phase II and III studies have demonstrated that these agents reduce LDL-C levels by up to 60% and are relatively safe, with the exception of injection site reactions. Additionally, two randomized controlled clinical trials have demonstrated that both alirocumab and evolocumab reduce ASCVD events when used in combination with statin therapy compared to statin alone. In light of this evidence, the 2018 Cholesterol Guideline incorporated PCSK9 inhibitors into the treatment algorithm for select secondary prevention patients unable to achieve an LDL-C below 70 mg/dL despite maximally tolerated statin plus ezetimibe. Although PCSK9 inhibitors provide substantial reductions in LDL-C levels and reduce ASCVD events in secondary prevention populations, the cost-effectiveness of alirocumab and evolocumab limit widespread use. Additional research is needed to explore the role of PCSK9 inhibitors in other populations, including primary prevention, patients unable to tolerate statins, and acute myocardial infarction.

Combination therapy with once-weekly glucagon like peptide-1 receptor agonists and dipeptidyl peptidase-4 inhibitors in type 2 diabetes: a case series.

BACKGROUND: National treatment guidelines recommend glucagon-like peptide receptor agonists (GLP-1 RAs) as add-on therapy to oral agents. However, GLP-1 RAs in combination with dipeptidyl peptidase-4 (DPP-4) inhibitors is not recommended due to a lack of evidence. OBJECTIVE: This case series aims to describe the efficacy and safety of once-weekly GLP-1 RAs administered concomitantly with DPP-4 inhibitors in patients with type 2 diabetes. METHODS: A retrospective chart review of electronic medical records at a free health clinic was conducted between July 2014 and September 2016. Patients 18 years and older with type 2 diabetes were included if they received concomitant DPP-4 inhibitor and once-weekly GLP-1 RA therapy with at least one glycated hemoglobin A1c (HbA1c) measurement within three to six months of starting the combination. The primary and secondary outcomes included change in HbA1c and weight, and patient reported adverse events. RESULTS: Out of forty-three patients that received combination DPP-4 inhibitor plus GLP-1 RA therapy, only eighteen received once-weekly GLP-1 RA. At 3 months, the median (IQR) HbA1c and weight change was -0.8% (-4.3 to 2%) and -0.4kg (-4.2 to 5.8 kg) respectively. No patients reached an HbA1c below 7% and only three patients (17%) reached a HbA1c less than 8%. Patient reported adverse effects included gastrointestinal disturbances (28%), hypoglycemic symptoms (17%), and injection site reactions (0.6%). CONCLUSIONS: Concomitant use of once-weekly GLP-1 RAs and DPP-4 inhibitors provides only modest improvement in glycemic control with minimal weight loss benefits, which is similar to monotherapy with either agent. The combination is unlikely to provide synergistic effects and is not cost effective. These data support the current recommendations against use of combined incretin therapy.

Recent Developments in the Role of Coenzyme Q10 for Coronary Heart Disease: a Systematic Review.

PURPOSE OF REVIEW: This review examines recent randomized clinical trials evaluating the role of coenzyme Q10 (CoQ10) in the management of coronary heart disease. RECENT FINDINGS: CoQ10 is one of the most commonly used dietary supplements in the USA. Due to its antioxidant and anti-inflammatory effects, CoQ10 has been studied extensively for possible use in managing coronary heart disease. One of the most common applications of CoQ10 is to mitigate statin-associated muscle symptoms (SAMS) based on the theory that SAMS are caused by statin depletion of CoQ10 in the muscle. Although previous studies of CoQ10 for SAMS have produced mixed results, CoQ10 appears to be safe. Because CoQ10 is a cofactor in the generation of adenosine triphosphate, supplementation has also recently been studied in patients with heart failure, which is inherently an energy deprived state. The Q-SYMBIO trial found that CoQ10 supplementation in patients with heart failure not only improved functional capacity, but also significantly reduced cardiovascular events and mortality. Despite these positive findings, a larger prospective trial is warranted to support routine use of CoQ10. Less impressive are the effects of CoQ10 on specific cardiovascular risk factors such as blood pressure, dyslipidemia, and glycemic control. Current evidence does not support routine use of CoQ10 in patients with coronary heart disease. Additional studies are warranted to fully determine the benefit of CoQ10 in patients with heart failure before including it in guideline-directed medical therapy.

The 2017 American College of Cardiology/American Heart Association hypertension guideline and opportunities for community pharmacists.

OBJECTIVES: To initiate a call to action for community pharmacists to maximize the opportunities to improve the management of hypertension (HTN) in light of the 2017 American College of Cardiology (ACC)/American Heart Association (AHA) HTN guideline. SUMMARY: In November 2017, the ACC and the AHA, along with 9 other professional organizations, released a comprehensive guideline on the prevention, detection, evaluation, and management of high blood pressure (BP). Major changes included the reclassification of BP and redefinition of HTN to 130/80 mm Hg or above, significantly increasing the number of individuals with HTN. The 2017 ACC/AHA HTN guideline also emphasized out-of-office BP readings and recommended team-based care models that include pharmacists and other health professionals as one strategy to improve BP control rates and provide appropriate follow-up and monitoring. Community pharmacists are highly accessible health professionals that now have an even greater opportunity to improve the monitoring and management of patients with HTN. Monitoring of BP in pharmacies could be greatly improved if BP kiosks were replaced by automated BP monitors operated by appropriately trained personnel that would initiate a face-to-face consultation with a community pharmacist. Physicians and other prescribers should also refer patients directly to their community pharmacists to receive assistance in selecting a home BP monitor. Given recent expansion of collaborative practice legislation and prescriptive authority, health information exchanges, and reimbursement models, community pharmacists have a renewed opportunity to collaborate with medical practices and health systems to improve BP control. In addition, greater collaboration among pharmacists practicing in primary care and community pharmacy could improve care coordination. CONCLUSION: Community pharmacists have a significant opportunity to collaborate with patients, physicians, and the health care community at large to improve the monitoring and management of HTN and ensure that the 2017 ACC/AHA HTN guideline is successfully implemented.

A Prescription for Prescribing: Ensuring Continued Pharmacist Preparedness.

The scope of practice for pharmacists in the United States increasingly includes elements of prescribing under collaborative practice agreements and statewide protocols. However, as a result of continued health care access concerns, we believe that pharmacists will be called on to serve as independent prescribers in the future. For this anticipated practice expansion to become a successful reality, the assurance of pharmacist preparedness and continuous professional development through profession-wide standards will be imperative.

Pharmacist-physician collaborative care model and time to goal blood pressure in the uninsured population.

Pharmacist-physician collaborative practice models (PPCPMs) improve blood pressure (BP) control, but their effect on time to goal BP is unknown. This retrospective cohort study evaluated the impact of a PPCPM on time to goal BP compared with usual care using data from existing medical records in uninsured patients with hypertension. The primary outcome was time from the initial visit to the first follow-up visit with a BP <140/90 mm Hg. The study included 377 patients (259 = PPCPM; 118 = usual care). Median time to BP goal was 36 days vs 259 days in the PPCPM and usual care cohorts, respectively (P < .001). At 12 months, BP control was 81% and 44% in the PPCPM and usual care cohorts, respectively (P < .001) and therapeutic inertia was lower in the PPCPM cohort (27.6%) compared with usual care (43.7%) (P < .0001). Collaborative models involving pharmacists should be considered to improve BP control in high-risk populations.

Pharmacists providing care in the outpatient setting through telemedicine models: a narrative review

Telemedicine refers to the delivery of clinical services using technology that allows two-way, real time, interactive communication between the patient and the clinician at a distant site. Commonly, telemedicine is used to improve access to general and specialty care for patients in rural areas. This review aims to provide an overview of existing telemedicine models involving the delivery of care by pharmacists via telemedicine (including telemonitoring and video, but excluding follow-up telephone calls) and to highlight the main areas of chronic-disease management where these models have been applied. Studies within the areas of hypertension, diabetes, asthma, anticoagulation and depression were identified, but only two randomized controlled trials with adequate sample size demonstrating the positive impact of telemonitoring combined with pharmacist care in hypertension were identified. The evidence for the impact of pharmacist-based telemedicine models is sparse and weak, with the studies conducted presenting serious threats to internal and external validity. Therefore, no definitive conclusions about the impact of pharmacist-led telemedicine models can be made at this time. In the Unites States, the increasing shortage of primary care providers and specialists represents an opportunity for pharmacists to assume a more prominent role managing patients with chronic disease in the ambulatory care setting. However, lack of reimbursement may pose a barrier to the provision of care by pharmacists using telemedicine (AU)

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Pharmacologic approaches for the management of patients with moderately elevated triglycerides (150-499 mg/dL).

Hypertriglyceridemia, defined as serum triglyceride (TG) levels >150 mg/dL, now affects over one-quarter of the US adult population and is associated with an increased risk of atherosclerotic cardiovascular disease. Available guidelines for managing hypertriglyceridemia vary with respect to TG thresholds and severity of disease. Lifestyle modifications and management of secondary causes (eg, diabetes) remain the first step in managing hypertriglyceridemia, with pharmacotherapy reserved to reduce the risk of pancreatitis and/or further reduce TG levels. Several classes of lipid-lowering agents are available with variable TG-lowering efficacy. Although there is no consensus regarding the choice of initial TG-lowering pharmacotherapy, there is general agreement that the decision depends on the degree of hypertriglyceridemia and atherosclerotic cardiovascular disease risk. This review will discuss available and emerging lipid-lowering therapies for the management of moderately elevated TG, defined as TG 150 to 499 mg/dL.

Pharmacists providing care in the outpatient setting through telemedicine models: a narrative review.

Telemedicine refers to the delivery of clinical services using technology that allows two-way, real time, interactive communication between the patient and the clinician at a distant site. Commonly, telemedicine is used to improve access to general and specialty care for patients in rural areas. This review aims to provide an overview of existing telemedicine models involving the delivery of care by pharmacists via telemedicine (including telemonitoring and video, but excluding follow-up telephone calls) and to highlight the main areas of chronic-disease management where these models have been applied. Studies within the areas of hypertension, diabetes, asthma, anticoagulation and depression were identified, but only two randomized controlled trials with adequate sample size demonstrating the positive impact of telemonitoring combined with pharmacist care in hypertension were identified. The evidence for the impact of pharmacist-based telemedicine models is sparse and weak, with the studies conducted presenting serious threats to internal and external validity. Therefore, no definitive conclusions about the impact of pharmacist-led telemedicine models can be made at this time. In the Unites States, the increasing shortage of primary care providers and specialists represents an opportunity for pharmacists to assume a more prominent role managing patients with chronic disease in the ambulatory care setting. However, lack of reimbursement may pose a barrier to the provision of care by pharmacists using telemedicine.