Efficiencies and outcomes of depression treatment by a psychiatric pharmacist in a primary care clinic compared with treatment within a behavioral health clinic.

OBJECTIVE: This study compared the efficiency and increased access to care by a psychiatric pharmacist (PP) incorporated into primary care versus behavioral health clinic (BHC) prescribers for depression treatment. SETTING: The pharmacist's practice was based in the primary care clinics of an urban Federally Qualified Community Health Center (FQCHC). PRACTICE DESCRIPTION: PP entered into a supervised collaborative practice agreement at the FQCHC. Primary care providers referred patients to PP for depression treatment. PRACTICE INNOVATION: PPs have been utilized as psychiatric providers within psychiatric settings, but not in primary care. Integrating a PP within primary care can assist patients in obtaining more rapid, individualized mental health treatment. EVALUATION: Investigators retrospectively screened the records of adults treated at a FQCHC with a primary diagnosis of depression referred for antidepressant management to (1) the PP over a 2 year period (study group [SG]), versus (2) the FQCHC's BHC over the year preceding the PP's arrival (control group [CG]). Both groups were compared using serial PHQ-9 data and wait time until initial evaluation. Pharmacist's patients treated during a 2-month period also completed a satisfaction survey. RESULTS: The SG and CG included 107 and 34 patients respectively. Average PHQ-9 scores decreased from 17.9 ± 6.51 at baseline to 14.7 ± 7.0 at follow-up #1 in the SG (P < 0.001), whereas there were minimal PHQ-9 data in CG. Time from treatment referral to initial medication evaluation averaged 31.3 days in the SG and 104.5 days in the CG (P < 0.001). The 39 SG patients demonstrated high satisfaction, with a mean of 26.8 out of 28 points. CONCLUSION: PP incorporation into primary care produced positive outcomes and improved depression treatment access. Patients maintained reduced PHQ-9 scores and were seen in one-third the time versus those seen in the BHC. PP utilization in primary care is viable for treating depression.

The Relationship between the Initial Anti-factor Xa Measurement and the Duration of Direct Oral Anticoagulant Influence in Patients Transitioning to Heparin.

BACKGROUND: Anticoagulation monitoring during transition from direct oral anticoagulants (DOAC) to heparin infusions is a significant challenge. Factor Xa inhibitors influence the heparin calibrated antifactor Xa assay. The University of Virginia (UVA) Medical Center utilized a corrected antifactor Xa assay (c-AXA) during this transition period, which removes DOAC-mediated antifactor Xa activity (d-AXA) and reflects heparin-specific activity. Currently, the duration of this influence is not well described. STUDY OBJECTIVE: This study had two aims: to determine if the initial d-AXA is predictive of the duration of DOAC influence and to further characterize this influence among different patient populations. METHODS: This retrospective study included adult patients admitted to UVA Medical Center between September 2016 and March 2017, with c-AXA measurements, who received apixaban or rivaroxaban within 48 hours before heparin initiation. A Pearson correlation test, Kaplan-Meier Survival Analysis, and multivariate linear regression were used to assess the relationship between initial d-AXA and duration of influence. RESULTS: Sixty-eight patients met inclusion criteria and were maintained on either apixaban (85%) or rivaroxaban (15%) before heparin initiation. The initial d-AXA ranged from 0.11 to 3.27 IU/ml. The mean duration of influence was 69.3 ± 46.2 hours, with a median duration of 62.7 hours. No strong correlation was identified between initial d-AXA and duration of influence (R2 = 0.124). Presence of interacting medications significantly increased duration of influence (p=0.012). No significant difference in duration of influence existed between patients with normal renal function and those with dynamic renal function (p=0.84), or with body mass index (BMI) greater than 40 kg/m2 (p=0.16). CONCLUSIONS: The initial d-AXA was not predictive of duration of influence in patients transitioning from DOACs to heparin infusion; however, the median duration of influence suggests influence may be present for longer than currently stated in the literature, especially in those taking interacting medications.

Alternative Pharmacological Management of Vasopressor Extravasation in the Absence of Phentolamine.

Vasopressor extravasation is a rare adverse drug reaction that can lead to tissue damage, ischemia, and necrosis of the affected area when vasopressors are administered peripherally. Phentolamine, a nonselective, reversible alpha antagonist, is the current standard treatment for this adverse reaction, but it is often unavailable for use. This review seeks to synthesize the available data in order to recommend alternative pharmacological options for use when phentolamine is not available. After an extensive literature search, 16 publications were reviewed. A treatment algorithm was created that recommends a combination of subcutaneous terbutaline, a selective beta2 agonist, and topical nitroglycerin, an organic nitrate, for adults; and topical nitroglycerin monotherapy for children younger than 2 years of age. However, further research and case reports are required in order to establish a new standard of care for the treatment of vasopressor extravasation.