Proton Pump Inhibitor Use in Older Adults: Long-Term Risks and Steps for Deprescribing.

Proton pump inhibitors (PPIs) are commonly prescribed for treatment of acid-related gastrointestinal disorders. PPI use is approved for a duration of 2 to 12 weeks, depending on complication and severity. Many users lack an appropriate indication for continued therapy past the recommended duration. Long-term PPI use is associated with several adverse drug events, including acute interstitial nephritis, fractures, and Clostridium difficile-associated diarrhea (CDAD). Cautious prescribing and regular monitoring is essential, especially for older adults, as they may be at higher risk for these adverse effects. Deprescribing, defined as lowering dosage, switching to as-needed use, or complete discontinuation, should be considered for many PPI users. Patient education is critical. Alternative therapy considerations include histamine-2-receptor antagonists, as they are found to be associated with reduced CDAD and fracture events. Additional strategies include tapering off PPIs and modifying lifestyle to reduce the potential rebound hypersecretion that may occur as a result of discontinuation. The most significant lifestyle modification is weight loss. Additional lifestyle interventions include upright head of bed elevation, avoiding meals close to bedtime, and avoiding high-fat meals within two to three hours of reclining.

Student and faculty perceptions about mandatory influenza vaccinations on a health sciences campus.

OBJECTIVE: To examine the perceptions among faculty and health professional students regarding mandatory vaccination policies on a health sciences campus. PARTICIPANTS: A total of 296 faculty and 244 students completed surveys during Fall 2015. METHODS: The online survey administered to individuals who received the influenza vaccine during the fall 2015 influenza vaccination clinic season included five items evaluating perceptions of employer mandatory vaccination requirements. RESULTS: Chi-square analysis indicated that although faculty and students agree mandatory vaccinations in a health care environment are appropriate, faculty are more likely than students to get vaccinated in the absence of a mandate. Additionally, a small fraction of faculty would consider employment elsewhere when facing this mandate. CONCLUSIONS: Overall, faculty and students had favorable perceptions about mandatory influenza vaccine policies. Since students were less likely to be vaccinated in the absence of a mandate, education of students should be improved to support the importance of vaccinations in a health care environment.

Review of the Next Generation of Long-Acting Basal Insulins: Insulin Degludec and Insulin Glargine.

Older adults are at an increased risk of developing type 2 diabetes mellitus (T2DM). Although oral agents (i.e., metformin) are the preferred first-line therapy, older adults often eventually require the addition of insulin to control their blood glucose. Long-acting insulin analogues are the preferred insulin products for older adults with T2DM. Insulin degludec and insulin glargine U-300 are both new generation long-acting insulins. When compared with the standard of care, long-acting insulin product insulin glargine U-100, insulin degludec, and insulin glargine U-300 had similar glucose-lowering effects, longer half-lives and durations of action, and a more even distribution over a 24-hour period. Additionally, the new generation insulins were superior with regard to rates and severity of nocturnal hypoglycemia. The long-term cardiovascular safety of these products has not been established yet. Although the new generation long-acting insulins will not revolutionize diabetes management, they appear to be an improvement over previous long-acting insulins.

Laboratory and Clinical Monitoring of Direct Acting Oral Anticoagulants: What Clinicians Need to Know.

The direct acting oral anticoagulants (DOACs), including dabigatran, rivaroxaban, apixaban, and edoxaban, have favorable pharmacokinetic and pharmacodynamic properties and equal or superior efficacy and an improved safety profile compared with warfarin. Noted shortcomings with DOACs are shorter half-lives requiring stricter adherence, lack of standardized laboratory monitoring, lack of anticoagulation reversal agents, and loss of routine coagulation monitoring leading to fewer patient-clinician interactions. This review addresses many of these limitations including monitoring of DOACs for efficacy and toxicity, an assessment of selected qualitative and quantitative tests, and development of monitoring strategies for special populations. Coagulation monitoring is generally recommended only in overdose situations, but once standardized assays are readily available, they could be helpful to ensure efficacy, assess bleeding, and aid in drug selection in a number of other patient scenarios. Coagulation tests that may provide qualitative assessment include activated partial thromboplastin time, prothrombin time, and thrombin time. Methods with potential utility for quantitative assessment of DOACs include plasma drug concentrations, ecarin clotting time, dilute thrombin time, and anti-factor Xa concentrations. Noncoagulation laboratory monitoring should include serum creatinine, liver function tests, and complete blood counts. Clinical monitoring of the DOAC-treated patient should include routine assessment of adherence, bleeding risks, and drug interactions. Frequency of monitoring should be 1-3 months after initiation and then at least every 6 months, with more frequent follow-up (i.e., 3 months) based on patient specific characteristics such as age, renal impairment, hepatic impairment, and concomitant drug therapy. The authors provide a practical tool to assist in DOAC monitoring and recommend that pharmacists collaborate with physicians in selecting appropriate patients and tailoring patient-specific monitoring plans.

Analysis of a Genetic Polymorphism in the Costimulatory Molecule TNFSF4 with Hematopoietic Stem Cell Transplant Outcomes.

Despite stringent procedures to secure the best HLA matching between donors and recipients, life-threatening complications continue to occur after hematopoietic stem cell transplantation (HSCT). Studying single nucleotide polymorphism (SNP) in genes encoding costimulatory molecules could help identify patients at risk for post-HSCT complications. In a stepwise approach we selected SNPs in key costimulatory molecules including CD274, CD40, CD154, CD28, and TNFSF4 and systematically analyzed their association with post-HSCT outcomes. Our discovery cohort analysis of 1157 HLA-A, -B, -C, -DRB1, and -DQB1 matched cases found that patients with donors homozygous for the C variant of rs10912564 in TNFSF4 (48%) had better disease-free survival (P = .029) and overall survival (P = .009) with less treatment-related mortality (P = .006). Our data demonstrate the TNFSF4C variant had a higher affinity for the nuclear transcription factor Myb and increased percentage of TNFSF4-positive B cells after stimulation compared with CT or TT genotypes. However, these associations were not validated in a more recent cohort, potentially because of changes in standard of practice or absence of a true association. Given the discovery cohort, functional data, and importance of TNFSF4 in infection clearance, TNFSF4C may associate with outcomes and warrants future studies.

Interprofessional pharmacy observation activity for third-year dental students.

Interprofessional learning is a key component of today's health sciences education. Within a two-course series in dental pharmacology and therapeutics, a dental curriculum was revised to provide an interprofessional activity to expose dental students to a community pharmacy setting. The objectives of this activity were to augment students' learning about drug laws and prescription writing, as well as to foster interprofessional relationships and collaboration between pharmacists and dentists. Dental students were scheduled for one-hour observations at community pharmacies on campus. Learning objectives to guide this activity focused on demonstrating community pharmacy operating procedures, identifying ways to minimize prescribing and dosing errors, and understanding how pharmacists can assist dentists in prescribing. Following the observation, students were required to submit a written assignment, which accounted for 14 percent of their course grade. All 119 dental students (100 percent) enrolled in the course for the summers of 2012 and 2013 completed the activity. The average grade on the written assignment was 96.2 out of 100. At the end of the course, students were asked to participate in an online course evaluation survey, for which response rates were 37 percent and 43 percent for 2012 and 2013, respectively. The students rated the pharmacy observation activity favorably on this course evaluation. The pharmacy observation activity provided a successful interprofessional component to the didactic pharmacy course and was well received by the dental students as well as the community pharmacists.

Rivaroxaban for treatment of venous thromboembolism in older adults.

Rivaroxaban is a factor Xa inhibitor recently approved for use in the treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE). Older adults are at an increased risk for venous thromboembolism (VTE), and rivaroxaban offers an alternative to standard treatment including vitamin K antagonists. This review evaluates the literature supporting this new indication with a focus on the safety and efficacy in older adults as well as those with renal insufficiency and fragility, which the EINSTEIN-PE study defined as those older than 75 years of age, weighing 50 kg or less, or with a creatine clearance (Clcr) of less than 50 mL/min. Three large studies (EINSTEIN-PE, -DVT, -EXT) provide an evaluation of recurrent VTE and bleeding events with the use of rivaroxaban. EINSTEIN-DVT and EINSTEIN-PE showed rivaroxaban to be equivalent to standard treatment in the overall population as well as in older adults and those with renal insufficiency and fragility. Further, EINSTEIN-EXT showed benefit of rivaroxaban over placebo for extended VTE protection (i.e., longer than 6 to 12 months of treatment), both overall and in the subgroups of those older than 75 years of age and with a Clcr of 50 mL/min to < 80 mL/min..

Influenza vaccination by pharmacists in a health sciences center: A 3-year experience.

OBJECTIVE: To assess the design and implementation of influenza vaccination clinics across campus, assess participant satisfaction with the pharmacist-led clinics, and educate and increase visibility of the role of pharmacists as vaccinators. SETTING: University of Oklahoma Health Sciences Center (OUHSC), a comprehensive health sciences center. PRACTICE INNOVATION: The College of Pharmacy on the OUHSC campus developed and implemented a vaccination program to increase influenza vaccination of OUHSC employees. MAIN OUTCOME MEASURES: Number of employees receiving influenza vaccination, employee satisfaction with the pharmacist-led clinics, and employee awareness of the pharmacist's role in vaccination. RESULTS: Reported OUHSC employee influenza vaccination rates increased from approximately 35% before implementation of the pharmacy-based program to 54% in 2012 after implementation. The increase was attributed to maintaining no out-of-pocket costs for employees, offering various clinic locations, and using media resources to educate employees about influenza infection and vaccination. Employees reported high satisfaction with the influenza vaccination clinics and with receiving vaccinations from pharmacists and student pharmacists. In the first 2 years of the program, the percentage of surveyed employees "very familiar" with the pharmacist's role in vaccinations increased from 23% to 66%. CONCLUSION: A college of pharmacy on a large health sciences center developed and successfully implemented an influenza vaccination program, providing an accessible and convenient route for influenza prevention to employees, as well as enhanced the visibility of pharmacists as vaccination providers.

Evaluation of dabigatran exposures reported to poison control centers.

BACKGROUND: Dabigatran is a novel oral anticoagulant for which a well-defined range of toxicity and proven antidote has not been established. OBJECTIVE: The primary objective of this study was to characterize dabigatran exposures reported to poison centers by dose ingested, clinical effects, treatments used, and managment sites to gain a better understanding of patient outcomes. METHODS: A retrospective database review was conducted for dabigatran exposures reported to the National Poison Data System for the American Association of Poison Control Centers (AAPCC) over the period October 2010 to December 2012. RESULTS: There were 802 human dabigatran exposures involving adults predominantly (91% of cases). Exposure chronicity was acute in 43%, acute-on-chronic in 46%, and chronic in 11%, with the most common reason for an exposure call being an unintentional therapeutic error (70.6%). The most common management sites were on-site in 72% of cases and within a health care facility for 26%. Bleeding events and coagulopathies were the most commonly observed clinical effects. Treatments administered included activated charcoal, blood and coagulation products, hemodialysis, and supportive measures. Confirmed outcomes included death in 13 patients (1.6%), major effects in 23 (2.9%), and moderate effects in 50 (6.2%). More severe outcomes were significantly associated with adverse drug reactions, patients ≥65 years of age, those treated with blood and coagulation products and/or dialysis, and renal dysfunction (P < .05). Children experienced few moderate effects and no major effects or deaths. CONCLUSIONS: Severe outcomes from dabigatran exposures were not common, occurring in approximately 5% of cases.

The impact of problem-solving feedback on team-based learning case responses.

OBJECTIVE: To determine the amount and type of feedback needed to improve pharmacy students' problem-solving skills using team-based learning (TBL) and a problem-solving rubric. METHODS: A problem-solving rubric was developed to assess the ability of pharmacy students' to prioritize, organize, and defend the best and alternative options on TBL cases The study involved 3 groups of pharmacy students: second-year students in a cardiology class who received no feedback (control group), third-year students in an endocrinology class who received written feedback only, and third-year students in an endocrinology class who received written and verbal feedback. Students worked in groups on all TBL cases except the first and last one (beginning and end of course), which students completed independently as it served as a pretest and posttest. RESULTS: Significant improvements were seen in the ability of the third-year students who received verbal and written feedback to prioritize the information presented in the case and in their total score on the problem-solving rubric. CONCLUSION: Providing pharmacy students with written and verbal explanations may help them improve their problem-solving skills overall. During verbal feedback, faculty members can provide more examples of how to improve and can field questions if needed.

Introductory and advanced pharmacy practice experiences within campus-based influenza clinics.

OBJECTIVE. To describe the development, implementation, and assessment of an introductory and an advanced pharmacy practice experience (IPPE and APPE) integrated within campus-based influenza clinics. DESIGN. The influenza clinics were designed to incorporate the learning objectives for the IPPE and APPE, and included preparatory sessions, online learning, and direct patient interactions tailored to the appropriate education level of the learner. ASSESSMENT. The clinics provided influenza vaccinations to 2,292 and 2,877 individuals in 2010 and 2011, respectively. The clinics allowed for experiential education of 39 students earning a total of 467 IPPE and APPE hours in 2010 and 58 students earning a total of 656 IPPE and APPE hours in 2011. Third-year students were assessed before and after completing the IPPE, and improvement was seen in knowledge and self-ratings of perceptions and attitudes toward administering immunizations. CONCLUSIONS. Integrating pharmacy practice experiences within campus-based influenza clinics was an effective way to provide students with direct patient care experience and preventive health services knowledge.

Use of bisphosphonates in older adults: how long is long enough?

OBJECTIVE: To assess the benefits and risks of long-term bisphosphonates for treatment of osteoporosis in older adults. DATA SOURCES: A MEDLINE search was performed using PubMed from 1966 through 2011 to identify relevant publications. Key words searched included: adverse effects (AEs), aged, alendronate, atrial fibrillation, atypical fractures, bisphosphonate-associated osteonecrosis of the jaw, bisphosphonates, diaphyseal fractures, gastrointestinal cancer, ibandronate, musculoskeletal pain, osteoporosis, risedronate, subtrochanteric fractures, and zoledronic acid. Additional sources were obtained through bibliographic review of selected articles. STUDY SELECTION: Relevant studies that examined efficacy and safety of bisphosphonates in the treatment of osteoporosis were included. Focus was given to data involving older adults. Stronger levels of evidence (prospective trials) were given preference as the predominant body of literature, when available. DATA SYNTHESIS: Osteoporosis affects millions of elderly patients. Bisphosphonates represent first-line therapy. Recent literature has heightened concerns regarding AEs associated with long-term use, leading to the proposition of a "drug holiday." Additionally, there is a lack of literature concerning management of bisphosphonates in older adults. CONCLUSION: Evidence indicates that bisphosphonates maintain their efficacy and safety in older adults. Consideration must be given on a case-by-case basis to potential AEs associated with long-term use, as well as the derived benefit. Drug holidays may be appropriate given consideration of certain patient characteristics. Well-designed, prospective studies are needed to evaluate long-term use and AEs in older adults; therefore, clinical judgment combined with available evidence will have to suffice as the current practice.

Effect of oral diuretics on chronic warfarin therapy: a retrospective study.

BACKGROUND: Limited clinical documentation is suggestive of a drug interaction between warfarin and diuretics. OBJECTIVE: To evaluate the effect on international normalized ratio (INR) when a daily oral diuretic is started or increased in patients on chronic stable warfarin therapy. METHODS: The medical records of all active patients of two hospital-based anticoagulation clinics were retrospectively reviewed to identify patients who were started on or received a dose increase of a daily oral diuretic while on stable warfarin therapy. The primary endpoint was the mean difference between an INR recorded within 30 days prior to the diuretic initiation (pre-INR) and an INR recorded within 30 days after diuretic initiation (post-INR). RESULTS: A total of 1254 patient charts were screened and a total of 123 patients met the study criteria. The mean difference in pre-INR and post-INR was 0.09 (95% CI -0.03 to 0.21, p = 0.12). Post-INR values were outside of the patient's therapeutic range in 39 patients (32%), but no major bleeding or thromboembolic events were reported. CONCLUSION: Based on this retrospective study, diuretics did not result in a significant change in the INR in patients on stable warfarin therapy.

Assessment of streams of knowledge, skill, and attitude development across the doctor of pharmacy curriculum.

OBJECTIVE: To continue efforts of quality assurance following a 5-year curricular mapping and course peer review process, 18 topics ("streams") of knowledge, skills, and attitudes were assessed across the doctor of pharmacy (PharmD) curriculum. DESIGN: The curriculum committee merged the 18 topics into 9 streams. Nine ad hoc committees ("stream teams") of faculty members and preceptors evaluated the content, integration, and assessment for their assigned streams across the 4 professional years. Committees used a reporting tool and curriculum database to complete their reviews. ASSESSMENT: After each team presented their findings and recommendations at a faculty retreat, the 45 faculty members were asked to list their top priorities for curriculum improvement. The 5 top priorities identified were: redefinition and clarification of program outcomes; improved coordination of streams across the curriculum; consistent repetition and assessment of math skills throughout the curriculum; focused nonprescription and self-care teaching into an individual course; and improved development of problem solving. CONCLUSIONS: This comprehensive assessment enabled the college to identify areas for curriculum improvement that were not readily apparent to the faculty from prior reviews of individual courses.

Integration of team-based learning strategies into a cardiovascular module.

OBJECTIVES: To integrate components of team-based learning (TBL) into a cardiovascular module to increase students' responsibility for their own learning and actively engage students across 2 campuses in patient cases. DESIGN: An existing cardiovascular course module was modified by replacing 8 hours of lectures with self-directed learning (SDL) assignments and transforming case discussion sessions using TBL methodologies. Case discussions were delivered using TBL methods to increase engagement of all students across both campuses while maintaining a low faculty-to-student ratio in the classrooms. Readiness assurance quizzes were performed with each SDL assignment and TBL case session. ASSESSMENT: Student and faculty satisfaction improved with the addition of SDL assignments and TBL cases without adverse effects on grades in the wake of the 14% decrease in lecture time. Total faculty time required increased primarily in the first year because of development of course materials. CONCLUSION: A modified TBL format was successfully integrated into a lecture-based cardiovascular module, resulting in improved student and faculty satisfaction with the course and no adverse effect on student performance.

Donor and recipient chemokine receptor CCR5 genotype is associated with survival after bone marrow transplantation.

Despite continual improvement, morbidity and mortality after hematopoietic stem cell transplantation (HSCT) remain high. The importance of chemokines in HSCT lies in their regulation of immune responses that determine transplantation outcomes. We investigated the role of recipient and donor chemokine system gene polymorphisms by using a candidate gene approach on the incidence of graft-versus-host disease and posttransplantation outcomes in 1370 extensively human leukocyte antigen-matched, unrelated donor-recipient pairs by using multivariate Cox regression models. Our analysis identified that recipients homozygous for a common CCR5 haplotype (H1/H1) had better disease-free survival (DFS; P = .005) and overall survival (P = .021). When the same genotype of both the donor and recipient were considered in the models, a highly significant association with DFS and overall survival was noted (P < .001 and P = .007, respectively) with absolute differences in survival of up to 20% seen between the groups at 3 years after transplantation (50% DFS for pairs with recipient CCR5 H1/H1 vs 30% for pairs with donor CCR5 H1/H1). This finding suggests that donor and/or recipient CCR5 genotypes may be associated with HSCT outcome and suggests new diagnostic and therapeutic strategies for optimizing therapy.