Interventions and impact of pharmacist-delivered services in perioperative setting on clinically important outcomes: a systematic review and meta-analysis.

Background: The perioperative arena is a unique and challenging environment that requires coordination of the complex processes and involvement of the entire care team. Pharmacists' scope of practice has been evolving to be patient-centered and to expand to variety of settings including perioperative settings. Objectives: To critically appraise, synthesize, and present the available evidence of the characteristics and impact of pharmacist-led interventions on clinically important outcomes in the perioperative settings. Design: A systematic review and meta-analysis. Methods: We searched PubMed, Embase, and CINAHL from index inception to September 2023. Included studies compared the effectiveness of pharmacist-led interventions on clinically important outcomes (e.g. length of stay, readmission) compared to usual care in perioperative settings. Two independent reviewers extracted the data using the DEPICT-2 (Descriptive Elements of Pharmacist Intervention Characterization Tool) and undertook quality assessment using the Crowe Critical Appraisal (CCAT). A random-effect model was used to estimate the overall effect [odds ratio (OR) for dichotomous and standard mean difference (SMD) for continuous data] with 95% confidence intervals (CIs). Results: Twenty-five studies were eligible, 20 (80%) had uncontrolled study design. Most interventions were multicomponent and continuous over the perioperative period. The intervention components included clinical pharmacy services (e.g. medication management/optimization, medication reconciliation, discharge counseling) and education of healthcare professionals. While some studies provided a minor description in regards to the intervention development and processes, only one study reported a theoretical underpinning to intervention development. Pooled analyses showed a significant impact of pharmacist care compared to usual care on length of stay (11 studies; SMD -0.09; 95% CI -0.49 to -0.15) and all-cause readmissions (8 studies; OR 0.60; 95% CI 0.39-0.91). The majority of included studies (n = 21; 84%) were of moderate quality. Conclusion: Pharmacist-led interventions are effective at improving clinically important outcomes in the perioperative setting; however, most studies were of moderate quality. Studies lacked the utilization of theory to develop interventions; therefore, it is not clear whether theory-derived interventions are more effective than those without a theoretical element. Future research should prioritize the development and evaluation of multifaceted theory-informed pharmacist interventions that target the whole surgical care pathway.

The impact of pharmacist activities on clinical outcomes in perioperative settings Why was the study done? The time around the surgery imposes significant risks to patient's health. While technical aspects of a procedure are important, it should be combined with the provision of optimal healthcare quality to increase the likelihood of desired clinical outcomes. Pharmacists are effective healthcare team members who have the potential to improve patient's outcomes in the perioperative settings. It is hence imperative to explore the roles and impact of clinical pharmacists in these settings. Thus far, there is no synthesis of literature regarding the pharmacist roles and effectiveness in the perioperative setting. What did the researchers do? We aimed to summarize and appraise the quality of evidence on the characteristics and impact of pharmacist activities on clinical outcomes in the perioperative settings. Three library databases were examined to identify studies eligible for inclusion. Two authors extracted data and assessed the quality of included studies. Statistical analysis was used to look at the success of the pharmacist interventions on different endpoints. What did the researchers find? A total of 25 studies were included. Most pharmacist activities consisted of multiple components (such as medication management and educating other healthcare providers) and spanned the whole perioperative journey. The analysis of included studies showed that pharmacist activities reduced the elapsed time in hospital and the number of times a patient winds up going back to a hospital after discharge. Most studies did not discuss the methods adopted to develop pharmacist activities. What do the findings mean? A number of pharmacist activity types were shown to be successful in reducing the duration of hospitalization and readmission episodes. New directions for future research should investigate the development of pharmacist-led interventions in terms of structure and processes to ensure the reproducibility of these interventions.

Effect of pharmacist care on clinical outcomes and therapy optimization in perioperative settings: A systematic review.

DISCLAIMER: In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE: Integration of pharmacists into the perioperative practice has the potential to improve patients' clinical outcomes. The aim of this systematic review is to systematically investigate the evidence on the roles of pharmacists in perioperative settings and the effects of pharmacist interventions on clinical outcomes and therapy optimization. METHODS: A protocol-led (CRD42023460812) systematic review was conducted using search of PubMed, Embase, CINAHL and Google Scholar databases. Studies that investigated the roles and impact of pharmacist-led interventions in the perioperative settings on clinical outcomes were included. Data were extracted and quality assessed independently by two reviewers using the DEPICT-2 (Descriptive Elements of Pharmacist Intervention Characterization Tool) and the Crowe Critical Appraisal Tool (CCAT), respectively. Studies were grouped according to the clinical area into 5 sections: (1) pain control and opioid consumption; (2) venous thromboembolism (VTE); (3) surgery-related gastrointestinal complications; (4) postoperative medication management; and (5) total parenteral nutritional. RESULTS: Nineteen studies involving a total of 7,168 patients were included; most studies were conducted in gastrointestinal (n = 7) and orthopedics (n = 6) surgical units. Most included studies (n = 14) employed a multicomponent intervention including pharmaceutical care, education, guideline development, drug information services, and recommendations formulation. The processes of developing the implemented interventions and their structures were seldom reported. Positive impacts of pharmacist intervention on clinical outcomes included significant improvement in pain control and reductions in the incidence of VTE, surgery-related stress ulcer, nausea, and vomiting. There is inconsistency in the findings related to medication management (ie, achieving desired therapeutic ranges) and management of chronic conditions (hypertension and type 2 diabetes). CONCLUSION: Whilst there is some evidence of positive impacts of pharmacist intervention on clinical outcomes and optimizing drug therapy, this evidence is generally of low quality and insufficient volume. While this review suggests that pharmacists have essential roles in improving the care of patients undergoing surgery, more research with rigorous designs is required.

Profile of tirzepatide in the management of type 2 diabetes mellitus: design, development, and place in therapy.

INTRODUCTION: Type 2 diabetes mellitus (T2DM) is one of the leading causes of morbidity and mortality. Peptide-based multi-targeting agonists represent a new paradigm in metabolic pharmacology as they manifest multiplexed pharmacological actions over mono-agonists. Tirzepatide is a novel dual glucose-dependent insulinotropic polypeptide receptor (GIPR) and glucagon-like peptide-1 receptor (GLP-1R) agonist that has been recently approved by the FDA. This review aims to summarize the available evidence on the discovery, pharmacology, pharmacokinetic, pharmacodynamic, efficacy, and safety of tirzepatide in the pharmacotherapy of T2DM. AREAS COVERED: We searched PubMed, Embase, and International Pharmaceutical Abstracts to identify relevant papers on tirzepatide use in T2DM. Clinical trial registries were also searched. EXPERT OPINION: Tirzepatide improves glycemic control compared to baseline, placebo, and active comparators. It is also associated with weight reduction and an improvement in some, but not all, dyslipidemia, cardiovascular risk, and nonalcoholic steatohepatitis (NASH) biomarkers. Tirzepatide has a favorable safety profile with a low risk of hypoglycemia; however, adverse events such as gastrointestinal reactions were frequently reported and sometimes even led to therapy discontinuation. Future research should focus on investigating the role of tirzepatide in obesity, NASH, and cardio-renal benefits. Real-world observational studies are also needed to assess rare and long-term adverse events.

The determination of causality of drug induced liver injury in patients with COVID-19 clinical syndrome.

BACKGROUND: Drug induced liver injury (DILI) is a rising morbidity amongst patients with COVID-19 clinical syndrome. The updated RUCAM causality assessment scale is validated for use in the general population, but its utility for causality determination in cohorts of patients with COVID-19 and DILI remains uncertain. METHODS: This retrospective study was comprised of COVID-19 patients presenting with suspected DILI to the emergency department of Weill Cornell medicine-affiliated Hamad General Hospital, Doha, Qatar. All cases that met the inclusion criteria were comparatively adjudicated by two independent rating pairs (2 clinical pharmacist and 2 physicians) utilizing the updated RUCAM scale to assess the likelihood of DILI. RESULTS: A total of 72 patients (mean age 48.96 (SD ± 10.21) years) were examined for the determination of DILI causality. The majority had probability likelihood of "possible" or "probable" by the updated RUCAM scale. Azithromycin was the most commonly reported drug as a cause of DILI. The median R-ratio was 4.74 which correspond to a mixed liver injury phenotype. The overall Krippendorf's kappa was 0.52; with an intraclass correlation coefficient (ICC) of 0.79 (IQR 0.72-0.85). The proportion of exact pairwise agreement and disagreement between the rating pairs were 64.4%, kappa 0.269 (ICC 0.28 [0.18, 0.40]) and kappa 0.45 (ICC 0.43 [0.29-0.57]), respectively. CONCLUSION: In a cohort of patients with COVID-19 clinical syndrome, we found the updated RUCAM scale to be useful in establishing "possible" or "probable" DILI likelihood as evident by the respective kappa values; this results if validated by larger sample sized studies will extend the clinical application of this universal tool for adjudication of DILI.

An investigation into the avoidability of drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome.

Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a rising morbidity amongst hospitalized patients. Whilst clinical protocols for the management of individual DRESS cases have been well established, determination of potential prevention of these cases by utilizing novel "avoidability" tools has remained unexplored. This retrospective study reviewed records of patients who presented to the emergency department of Weill Cornell Medicine-affiliated Hamad General Hospital, Doha Qatar with suspected DRESS syndrome. These cases were independently adjudicated (utilizing the RegiSCAR, and JSCAR tools) as DRESS-drug pairs by a team of two clinical pharmacists and two General Physicians. They were then rated for potential avoidability with the Liverpool adverse drug reactions avoidability tool (LAAT) by the same team of raters. A total of 16 patients satisfied RegiSCAR criteria for DRESS syndrome. The mean age of the study population was 41.5 years (SD ± 13.3). The study population was predominantly male (n = 12; [75%]). The median latent period from drug ingestion to clinical presentation was 14 days (interquartile range [IQR] 6.5, 29). The median RegiSCAR and J-SCAR scores were 6 (IQR 5, 6.8), 5 (IQR 4, 5.8) respectively. Utilizing the LAAT, about 60% of the DRESS syndrome-drug pairs were rated as "avoidable" ("probable" or "definite"). The overall Krippendorf's alpha with the LAAT was 0.81 (SE 0.10, CI 0.59-1.00); with an intraclass correlation coefficient (ICC) of 0.90 (CI 0.77, 0.96.). In a randomly selected cohort of DRESS syndrome-drug pairs, a significant proportion was potentially avoidable ("possibly" and "definitely") utilizing the LAAT. This will need validation by larger sample-sized prospective studies utilizing the updated LAAT proposed by this study.