Identification of risk factors associated with acute kidney injury in patients taking sodium-glucose cotransporter-2 inhibitors.

STUDY OBJECTIVE: Studies have demonstrated sodium-glucose cotransporter-2 (SGLT2) inhibitors are kidney protective; however, their ability to cause hemodynamic changes may predispose patients to acute kidney injury (AKI). An FDA warning recommends evaluating for factors that predispose patients to AKI before initiating a SGLT2 inhibitor. The primary objective of this study is to identify risk factors that may predispose persons with diabetes to AKI when initiating SGLT2 inhibitor therapy. DESIGN: Multicenter retrospective cohort chart review. DATA SOURCE: Study patients were identified through an electronic medical record generated report if they had type 2 diabetes and were prescribed a SGLT2 inhibitor from January 2013 to September 2019. PATIENTS: Patients were included if they were receiving care at Advocate Medical Group and were confirmed to have taken one of the four SGLT2 inhibitors available at the time of study approval, canagliflozin, dapagliflozin, empagliflozin, or ertugliflozin, for at least 7 days. Patients were excluded if they did not have a basic metabolic panel or comprehensive metabolic panel recorded 1 year prior to or 6 months after SGLT2 inhibitor therapy initiation. RESULTS: Data extraction from the electronic medical record identified 6425 patients receiving a SGLT2 inhibitor, of which 1962 met inclusion criteria and were included for analysis. Thirty-five (1.8%) patients experienced an AKI after SGLT2 inhibitor therapy initiation. There was no statistically significant difference between groups based on background medication use (p = 0.325). At baseline, patients experiencing an AKI after SGLT2 inhibitor initiation were more likely to be older in age (p = 0.010), have a higher serum potassium (p < 0.001), blood glucose (p = 0.018), SCr (p = 0.009) and UACR (p < 0.001), and a lower eGFR (p = 0.028) compared to those who did not experience AKI. CONCLUSIONS: The transient eGFR decline with SGLT2 inhibitor initiation should be expected and is generally not an indication to discontinue therapy. Future initiatives should be directed at increasing knowledge of monitoring recommendations for these agents.

Deprescribing in type 2 diabetes and cardiovascular disease: Recommendations for safe and effective initiation of glucagon-like peptide-1 receptor agonists in patients on insulin therapy.

Select glucagon-like peptide-1 (GLP-1) receptor agonists have demonstrated cardiovascular benefits in both primary and secondary prevention populations and are recommended in multiple guidelines for cardiovascular risk reduction in people with type 2 diabetes (T2D). Despite this, uptake of GLP-1 receptor agonists in clinical practice has been lagging. While the etiology of their underuse is multifactorial, lack of comfortability in adding a GLP-1 receptor agonist to established insulin regimens is a common barrier. Adjustments to basal and bolus insulin doses upon initiation of GLP-1 receptor agonists in trials have varied. When recommending empiric dose adjustments during initiation of GLP-1 receptors agonists, the most recent A1C and the current blood glucose levels, if available, should be taken into consideration. When initiating in a person being managed with basal-only insulin regimens, an empiric 20 % dose reduction is recommended if the baseline A1C is ≤8 %. For individuals using intensive insulin regimens, empiric dose reductions of up to 25 % in basal and 50 % in bolus therapy were implemented and summarized further in this review. Overall, initiation of GLP-1 receptor agonists can decrease insulin requirements and may permit deintensification of antihyperglycemic therapy through the reduction or discontinuation of bolus insulin therapy. As a result, this simplified regimen promotes increased adherence, reduces glycemic variability and hypoglycemia, and improves overall glycemic management and quality of life. This review aims to serve as a guide for clinicians to facilitate the initiation of GLP-1 receptor agonists and deintensification of insulin by providing suggested dose adjustments based on available literature.

Advocating for the pharmacy profession through involvement in a type 1 diabetes day camp as a pharmacy residency learning experience.

OBJECTIVE: Diabetes summer camps have the common objectives of providing children with diabetes a safe environment to have fun and develop skills to manage diabetes in the presence of variable physical activity and nutritional intake. Historically, the American Diabetes Association (ADA) has relied on nurses, dietitians, and physicians to serve as medical staff, whereas pharmacists served in educational roles. This commentary describes the experience of postgraduate year-2 (PGY-2) ambulatory care pharmacy residents participating as medical staff in the management of children with type 1 diabetes (T1D) at a week-long, summer day camp in an elective learning experience. DESCRIPTION: Two PGY-2 residents volunteered at ADA-sponsored camps in July and August 2017, in which they were responsible for performing and documenting blood glucose measurements, dosing and administering insulin, overseeing the use of insulin pumps and continuous glucose monitors, and managing cases of hypo- and hyperglycemias in children aged 4-9 years. They facilitated interprofessional education of other medical staff members, including discussions regarding pharmacokinetic profiles and formulations of various insulin products and performing advanced insulin dosing adjustments. SUMMARY: The perceived benefits of this residency learning experience included increased self-confidence regarding the management of T1D, insulin administration techniques, and interprofessional collaboration. Performing advanced clinical management of children with T1D increased awareness of pharmacists' skill set in diabetes care. Demonstrating this value in nontraditional care settings may increase the likelihood that pharmacists are recruited to interdisciplinary health care teams to participate in autonomous direct patient care. CONCLUSION: The PGY-2 ambulatory care pharmacy residents autonomously practiced as recognized medical staff in the management of pediatric patients with T1D. This experience advocates for pharmacists' and their trainees' involvement in service-learning and team-based medical care outside the traditional health care setting.

Validity and reliability pilot study of a tool for assessing ambulatory care pharmacist practice.

PURPOSE: The reliability and validity of a survey tool that aims to assess and stratify patient care services provided by ambulatory care pharmacists were evaluated. METHODS: The Tool for Assessing Ambulatory Care Pharmacist Practice (TAAPP) was developed by updating the Pharmaceutical Care Clinical Pharmacist Questionnaire. The TAAPP is organized into 2 sections that include 5 domains derived from the Pharmacists' Patient Care Process (PPCP). The first section of the TAAPP gathers the demographic information of the respondents as well as practice site characteristics. The second section aims to assess the activities that ambulatory care pharmacists participate in when providing direct patient care, stratified by PPCP domains. After the TAAPP was created, face validity was established by the study investigators and content validity was confirmed by 5 experts in ambulatory care pharmacy. Lastly, a reliability study was conducted and included pharmacists providing ambulatory care services in outpatient clinics who had been working at their clinical practice site for at least 2 years. The survey was disseminated electronically through a national pharmacy organization listserver. RESULTS: The results of this pilot study support both face and content validity of the TAAPP survey as well as internal consistency reliability of the TAAPP scores when used to evaluate pharmaceutical practices of ambulatory care pharmacists practicing in outpatient clinics throughout the United States. CONCLUSION: Internal consistency reliability testing demonstrated that the TAAPP scores were reliable with a Cronbach's α of >0.7 for each domain and the TAAPP overall.

The Effect of Clinical Pharmacists on Readmission Rates of Heart Failure Patients in the Accountable Care Environment.

BACKGROUND: Recent changes in the health care delivery landscape have expanded opportunities for clinical pharmacists in the ambulatory care setting. This article describes the successful integration of a clinical pharmacist-led chronic disease management service in a patient-centered medical home (PCMH) and accountable care organization (ACO) environment. PROGRAM DESCRIPTION: In 2008, the year before PCMH implementation, 36% of patients who were hospitalized at Advocate Trinity Hospital for a heart failure exacerbation were readmitted within 30 days of their hospital stay for heart failure exacerbation. This high rate of heart failure hospital readmissions, compared with national standards, drove the implementation of the PCMH at Advocate Medical Group - Southeast Center (AMG-SE), the adjoining outpatient medical clinic. A clinical pharmacist was added to the health care team to help achieve the collective goal of improving patient outcomes and decreasing hospitalizations. OBSERVATIONS: From November 1, 2009, through August 30, 2010, the clinical pharmacist conducted visits and intervened in the care of 111 chronic heart failure patients. A pre/post analysis of those 111 patients during the 10 months before and after the integration of the clinical pharmacist showed that those patients were hospitalized 63 times in the 10 months before having regularly scheduled visits with the clinical pharmacist and 30 times in the 10 months after establishing care. This reduction from 63 to 30 visits translated to an approximate 50% decrease in heart failure hospitalizations in patients being followed by the clinical pharmacist within the first 10 months. Once the clinical pharmacist became better integrated into the workflow through development of rapport with the medical team, the outcomes improved further. In an 18-month analysis from May 1, 2010, through November 30, 2011, only 2% of patients (3 of 153) designated as high-risk patients managed by the clinical pharmacist had a 30-day readmission for heart failure exacerbation. IMPLICATIONS: Outcomes-based models have expanded opportunities for clinical pharmacist involvement and can provide unique reimbursement options. Demonstration of cost savings and an improvement in quality measures are paramount to establishing and justifying the clinical pharmacist's role in a team-based model of care. DISCLOSURES: No outside funding supported this research. The authors have no conflicts of interest to disclose.

Time Spent, Workload, and Student and Faculty Perceptions in a Blended Learning Environment.

Objective. To evaluate student perception and time spent on asynchronous online lectures in a blended learning environment (BLE) and to assess faculty workload and perception. Methods. Students (n=427) time spent viewing online lectures was measured in three courses. Students and faculty members completed a survey to assess perceptions of a BLE. Faculty members recorded time spent creating BLEs. Results. Total time spent in the BLE was less than the allocated time for two of the three courses by 3-15%. Students preferred online lectures for their flexibility, students' ability to apply information learned, and congruence with their learning styles. Faculty members reported the BLE facilitated higher levels of learning during class sessions but noted an increase in workload. Conclusion. A BLE increased faculty workload but was well received by students. Time spent viewing online lectures was less than what was allocated in two of the three courses.

Assessment of pain and impact of care among patients with painful diabetic peripheral neuropathy.

OBJECTIVES To assess the prevalence of painful diabetic peripheral neuropathy (DPN), evaluate the impact of DPN on patients' function and quality of life, and assess patient satisfaction with their current DPN treatment. DESIGN Cross-sectional study. SETTING Patient-centered medical home model at an internal medicine clinic in Chicago, from November 1, 2011, through November 1, 2012. PARTICIPANTS 71 patients with type 1 or type 2 diabetes aged 45 to 85 years and receiving diabetes education and medication management from the clinic pharmacist. INTERVENTION Paper survey administered to patients during clinic visits. MAIN OUTCOME MEASURES DPN history; DPN impact on activity level, sleep, and quality of life; and satisfaction with current DPN treatment. RESULTS Of the 71 participants, 22% (n = 15) reported a diagnosis of DPN from their providers; however, 54% (n = 37) reported burning, aching, or tenderness in their hands, arms, legs, or feet. More than 50% of patients with these symptoms had experienced them for more than 1 year. Fewer than one in five patients (14% [n = 5]) reporting symptoms indicative of painful DPN were receiving treatment. CONCLUSION DPN may be underdiagnosed and undertreated in this patient population, which represents a potential opportunity for pharmacists to help patients with diabetes meet their quality of care goals.