The Medication Possession Ratio as a Predictor of Longitudinal HIV-1 Viral Suppression.

BACKGROUND: Antiretroviral adherence is essential to achieve viral suppression and limit HIV-related morbidity and mortality; however, antiretroviral adherence thresholds to achieve viral suppression in clinical practice have not been fully characterized using administrative claims data. OBJECTIVE: The purpose of this study was to assess the relationship between medication adherence and viral suppression among adult persons with HIV/AIDS (PWH) receiving antiretroviral therapy (ART) for ≥6 months. METHODS: This historical cohort, real-world investigation assessed maintenance of viral load suppression and viral load area-under-the-curve (vAUC) in PWH ≥18 years of age based on ART adherence. A marginal effects model was used to determine the predicted probabilities of final plasma HIV-1 RNA <50 copies/mL or vAUC <1,000 copy-days/mL according to the medication possession ratio (MPR), estimated using a Jackknife model variance estimator and a delta-method for marginal effects standard error. Tests for statistical significance used a Sidák method to correct for multiple comparisons. RESULTS: The mean MPR for ART was 86.7% (95% CI: 85.0%-88.4%) for the 372 PWH included in the study. The marginal effects analysis indicated that an MPR ≥82% was associated with a predicted probability of viral suppression <50 copies/mL (P < 0.05). Significant predicted probabilities for vAUC <1,000 copy-days/mL were observed with an MPR ≥90% (P < 0.05). CONCLUSION AND RELEVANCE: Medication possession ratio as a proxy for drug exposure was significantly and consistently associated with viral suppression using a longitudinal measure of HIV viremia. These findings can aid clinicians in the clinical management of PWH and inform future studies of adherence-viral suppression relationships with contemporary antiretroviral regimens.

Drug Prescribing: Clinical Pharmacists in Family Medicine.

Clinical pharmacists have added value to family medicine practices for decades. Postgraduate residency training and board certification are recommended for pharmacists in clinical and educational roles. Clinical pharmacists contribute to interprofessional health care teams by providing comprehensive medication management to ensure that drugs are safe, effective, and appropriate for the patients' conditions. Roles of such pharmacists include patient care, education, research, and administration. When incorporating a clinical pharmacist into a family medicine practice, it is critical to identify the needs, priorities, and roles of all health care team members. In the recruiting of a clinical pharmacist, candidates should be identified whose vision and values align with that of the practice. Finally, the effects of integration of the clinical pharmacist into the practice should be measured. Clinical pharmacists contribute to each goal of the Quadruple Aim, in addition to improved clinical, economic, and humanistic outcomes in the inpatient and outpatient settings. Although financial barriers may affect integration, many billing mechanisms have been implemented successfully by pharmacy practices for face-to-face and telehealth patient visits. Value-based reimbursement models support the inclusion of clinical pharmacists in the interprofessional health care team.

Drug Prescribing: New Drugs and Drug Classes in Family Medicine.

New drug approvals and safety information are constantly being released. Staying up-to-date can be a daunting task for family physicians. Several electronic resources provide valuable, concise information directly. It is important to be well informed about new drugs, and drug mechanisms, indications, and administration routes. Pertinent new drug mechanisms include calcitonin gene-related peptide receptor antagonists for migraine prevention, selective inhibitors of influenza cap-dependent endonuclease, and adenosine triphosphate-citrate lyase inhibitors for hypercholesterolemia. Dapagliflozin recently gained approval for heart failure with reduced ejection fraction with or without type 2 diabetes. Newly approved administration routes include oral semaglutide and intranasal esketamine and glucagon. Drug accessibility, cost, and advantages over existing drugs should be considered. Physicians also should search formularies and promptly respond to prior authorization requests. Physicians should be knowledgeable about drug safety updates, such as adverse events and drug recalls. When a drug has been recalled, it is imperative for prescribers to provide accurate patient advice and therapeutic alternatives. Clinical pharmacists are excellent resources for new drug information, formulary and cost savings management, and drug recall navigation.

Selective Serotonin Reuptake Inhibitor Use and Risk of Gastrointestinal and Intracranial Bleeding.

Selective serotonin reuptake inhibitors (SSRIs) are among the most commonly prescribed medications in the United States. Although SSRIs are highly tolerable relative to other antidepressants, they are associated with a number of adverse effects, including increased gastrointestinal tract bleeding and intracranial bleeding. Mechanisms include increased gastric acid secretion and inhibition of serotonin entrance into platelets. Patients with other bleeding risk factors, such as warfarin, clopidogrel, or aspirin use, may be at heightened risk of these adverse effects. The purpose of this article is to review the incidence of gastrointestinal tract bleeding or intracranial bleeding associated with concomitant SSRI use, the proposed mechanisms of, and the potential pharmacokinetic/pharmacodynamic interactions with anticoagulants and antiplatelets. Given the prevalence of SSRI use in the ambulatory setting, osteopathic physicians should be aware of potential drug-drug interactions and the clinical implications of SSRI-associated bleeding risk.

Use of the Muddiest Point Technique as an exam review in an integrated pharmacotherapy course.

BACKGROUND AND PURPOSE: The objective of this study was to evaluate the impact in student pharmacists' exam performance learning outcomes and satisfaction after integrating the Muddiest Point assessment technique into exam reviews. EDUCATIONAL ACTIVITY AND SETTING: In 2016, the Muddiest Point, a formative assessment tool, was used to develop exam review sessions for second-year student pharmacists in an integrated pharmacotherapy course focused on the cardiovascular system. Performance scores on all four exams were compared between students in the 2015 and 2016 courses. Students' complexity of learning was categorized using a taxonomy of learning structure. A survey was used to evaluate student perceptions of exam reviews and the Muddiest Point technique (MPT). FINDINGS: Scores were higher on the second exam for the 83 students in the 2016 course (78.0% vs. 86.0%, p<0.001). There was no difference on other exam scores or overall course failures. Muddiest points submitted by students demonstrated a variety of taxonomy of learning levels. Student pharmacists surveyed at the conclusion of the course agreed that exam reviews were helpful for their preparation for exams and that the MPT was a valuable use of class time. SUMMARY: Incorporating the MPT into exam reviews maintained exam scores and supported evaluation of student learning. In addition, student pharmacists were satisfied with this exam review method.

Statin-associated muscle symptoms and SLCO1B1 rs4149056 genotype in patients with familial hypercholesterolemia.

UNLABELLED: Patients with familial hypercholesterolemia (FH) may be at increased risk for statin-associated muscle symptoms because they require long-term treatment with high-intensity statin therapy. We sought to determine (1) whether other predisposing factors, including the well-known genetic variant associated with statin-associated muscle symptoms-solute carrier organic anion transporter family, member 1B1 (SLCO1B1) rs4149056-also increase the risk of statin-associated muscle symptoms in FH patients, and (2) the natural history and management for FH patients with statin-associated muscle symptoms. METHODS: We queried electronic records (2004-2014) of 278 genetically screened FH patients (113 men, 165 women; mean [SD] pretreatment low-density lipoprotein cholesterol [LDL-C] 259 [72] mg/dL) recruited from lipid clinics in the Dallas, TX, area from 2004 to 2014. Statin-associated muscle symptoms were defined as muscle symptoms arising while taking a statin and interrupting therapy. RESULTS: The risk of muscle symptoms was associated with age (odds ratio 1.6 [95% CI 1.2-2.2]), body mass index in non-African Americans (0.90 [0.83-0.97]), and hypertension (0.4 [0.2-0.9]). Simvastatin was the most commonly used statin, and it was the statin most associated with muscle symptoms. Among FH patients with muscle symptoms, 41% (n = 40) reestablished statin therapy ("eventually tolerant") and 29% (n = 28) never reestablished statin therapy ("never tolerant"). Rosuvastatin (43%) and pravastatin (30%) were the most common eventually tolerated statins, and eventually tolerant patients achieved lower treated LDL-C levels (eventually tolerant 127 vs never tolerant 192 mg/dL, P < .001). Never tolerant patients also developed muscle symptoms on nonstatins (16% vs 50%, P = .003). SLCO1B1 rs4149056 genotyping revealed 224 wild-type patients (TT) and 49 heterozygotes (TC). SLCO1B1 genotype was not associated with the risk of statin-associated muscle symptoms (odds ratio 1.40 [95% CI 0.74-2.64]). CONCLUSION: Age, not SLCO1B1 rs4149056 genotype, was the strongest risk factor for statin-associated muscle symptoms in FH patients. After developing muscle symptoms, many patients reestablished statin therapy and achieved significant LDL-C reductions. Overall, 10% of all FH patients had statin-associated muscle symptoms and never reestablished statin therapy. Such patients developed muscle symptoms even on nonstatin lipid-lowering drugs and continued to have elevations in LDL-C. Further insight is needed into the relationship between FH and statin-associated muscle symptoms so all FH patients can be adequately treated.

Glycemic index of American-grown jasmine rice classified as high.

The primary objective was to determine the glycemic index (GI) of jasmine rice grown in the United States (US). Secondary objective was to compare the GI of US grown jasmine rice to those grown in Thailand. Twelve healthy subjects were served all four brands of jasmine rice and a reference food (glucose), each containing 50 g of available carbohydrate. Fingerstick blood glucose was measured at 0, 15, 30, 45, 60, 90, and 120 min after consumption following a fasting state. The GI was calculated using the standard equation. The GI values for test foods ranged from 96 to 116 and were all classified as high GI foods. No difference in GI was found between American-grown and Thailand-grown jasmine rice. Although not statistically significant, observations show glycemic response among Asian American participants may be different. GI should be considered when planning meals with jasmine rice as the main source carbohydrate.