Evaluating the prescribing and monitoring of medications associated with QTc-prolongation in the ambulatory care setting.

RATIONALE: Little is known about the prescribing of medications with potential to cause QTc-prolongation in the ambulatory care settings. Understanding real-world prescribing of QTc-prolonging medications and actions taken to mitigate this risk will help guide strategies to optimize safety and appropriate prescribing among ambulatory patients. OBJECTIVE: To evaluate the frequency of clinician action taken to monitor and mitigate modifiable risk factors for QTc-prolongation when indicated. METHODS: This retrospective, cross-sectional study evaluated clinician action at the time of prescribing prespecified medications with potential to prolong QTc in adult patients in primary care. The index date was defined as the date the medication was ordered. Electronic health record (EHR) data were evaluated to assess patient, clinician and visit characteristics. Clinician action was determined if baseline or follow-up monitoring was ordered or if action was taken to mitigate modifiable risk factors (laboratory abnormalities or electrocardiogram [ECG] monitoring) within 48 h of prescribing a medication with QTc-prolonging risk. Descriptive statistics were used to describe current practice. RESULTS: A total of 399 prescriptions were prescribed to 386 patients, with a mean age of 51 ± 18 years, during March 2021 from a single-centre, multisite health system. Of these, 17 (4%) patients had a known history of QTc-prolongation, 170 (44%) did not have a documented history of QTc-prolongation and 199 (52%) had an unknown history (no ECG documented). Thirty-nine patients (10%) had at least one laboratory-related risk factor at the time of prescribing, specifically hypokalemia (16 patients), hypomagnesemia (8 patients) or hypocalcemia (19 patients). Of these 39 patients with laboratory risk factors, only 6 patients (15%) had their risk acknowledged or addressed by a clinician. Additionally, eight patients' most recent QTc was ≥500 ms and none had an ECG checked at the time the prescription was ordered. CONCLUSION: Despite national recommendations, medication monitoring and risk mitigation is infrequent when prescribing QTc-prolonging medications in the ambulatory care setting. These findings call for additional research to better understand this gap, including reasons for the gap and consequences on patient outcomes.

Centrally supported clinical pharmacist intervention to reduce clinical inertia in hypertension.

PURPOSE: To assess the impact of a one-time hypertension (HTN)-focused clinical pharmacist intervention on the occurrence of clinical inertia and change in blood pressure (BP). METHODS: This retrospective study included patients 18 to 89 years of age with a current diagnosis of HTN and average systolic BP of ≥150 mm Hg. Centralized outreach coordinators performed telephone outreach to patients to schedule an HTN-focused visit with their primary care provider (PCP) and forwarded outreach notes for half of these patients to clinical pharmacists embedded in an internal medicine clinic. The clinical pharmacists performed a one-time focused medication review and provided evidence-based recommendations to a patient's PCP prior to the scheduled appointment. The primary outcome was therapy intensification (medication adjustment or adherence discussion) as a measure of overcoming clinical inertia. Secondary outcomes were the mean changes in systolic and diastolic BP from preintervention values to 6-month follow-up in the intervention group versus the control group. RESULTS: A total of 91 patients were included, and 34 of 47 intervention patients (72%) had therapy intensification at the HTN-focused PCP appointment, compared to 20 of 44 control patients (46%) (P =0.017). The mean (SD) systolic BP reductions from baseline were 12.26 (29.04) mm Hg and 6.97 (27.05) mm Hg for the intervention and control groups, respectively (P =0.427), with diastolic BP reductions of 3.83 (13.14) mm Hg and 1.35 (10.60) mm Hg, respectively (P =0.380). CONCLUSION: A collaborative model involving centralized outreach coordinators and embedded clinical pharmacists led to a significant reduction in clinical inertia. This was a small-scale pilot study, and further research is needed to determine the effect of this intervention on BP reduction.

Diabetes: how to manage patients experiencing hypoglycaemia.

Hypoglycaemia is a complication associated with the management of both type 1 and type 2 diabetes. Despite newer technologies to help minimize the risk of hypoglycaemia, it remains a barrier for some patients to achieve optimal glycaemic control. In this review, the definitions and risk factors for hypoglycaemia will be briefly discussed and an in-depth review of the management for a conscious or unconscious patient in the outpatient and inpatient settings is provided. Rapid-acting glucose is the preferred treatment for a conscious patient regardless of the setting. For an unconscious patient, glucagon is preferred if the patient does not have intravenous (IV) access and dextrose can be used for patients with IV access. Until recently, there was only one formulation of glucagon, which had limitations due to the multiple steps required for reconstitution prior to administration in an emergency setting. This review also discusses the different glucagon formulations currently available for the management of hypoglycaemia.

Early impact of the 2018 AHA/ACC/multisociety cholesterol guideline on lipid monitoring after statin initiation.

BACKGROUND: The 2018 AHA/ACC/multisociety cholesterol guideline emphasizes the need for lipid monitoring more strongly than the previous 2013 guideline to ensure patients reach recommended percent low-density lipoprotein cholesterol reductions. Real-world compliance to monitoring recommendations is currently unknown. OBJECTIVES: This study examined the proportion of patients with a lipid panel measured within 3 months of statin initiation. METHODS: This retrospective cohort study evaluated University of Colorado Health primary care patients aged 18 to 89 years with a new statin prescription identified via the Epic Clarity database. Patients initiated on a statin during January 1, 2018 to June 30, 2018 and January 1, 2019 to June 30, 2019 were included in the pre-2018 guideline cohort and the post-2018 guideline cohort, respectively. Patients with active liver disease, pregnancy, or missing demographic data were excluded. RESULTS: A total of 13,726 patients were included, 7476 in the preguideline cohort and 6250 in the postguideline cohort. A total of 13.9% of patients in the preguideline cohort had a lipid panel completed within 3 months of statin initiation compared with 16.2% in the postguideline cohort (adjusted P < .001). In the postguideline cohort, 56% (n = 857) of patients with lipid monitoring warranted a therapeutic intensification as recommended by the 2018 guideline; however, only 5% had their lipid-lowering regimen changed. CONCLUSION: In a large integrated health system, lipid monitoring increased among patients newly started on statin therapy soon after release of the 2018 guideline but remains low. Clinical interventions are needed to improve lipid monitoring to optimize low-density lipoprotein cholesterol-lowering therapy and ensure that guideline-recommended goals are achieved.

Intranasal Glucagon: A New Way to Treat Hypoglycemic Emergencies.

Objective: To review the safety, efficacy, and administration of intranasal (IN) glucagon for the management of hypoglycemia. Data Source: A literature search of PubMed/MEDLINE (1995 to November 2019) using the terms intranasal glucagon, nasal glucagon, glucagon, hypoglycemia treatment, and hypoglycemia management was completed. Study Selection and Data Extraction: English-language studies evaluating IN glucagon were evaluated. Data Synthesis: IN glucagon is a newly approved product for the treatment of hypoglycemia in patients with diabetes, 4 years and older. Administered as a 3-mg dose, it was shown to be noninferior to intramuscular (IM) glucagon. In comparison trials, more than 98% of hypoglycemic events were treated successfully with IN glucagon in both pediatric and adult patients. In simulated and real-world studies, IN glucagon was administered in less than a minute for the majority of scenarios. IM glucagon took longer to administer, ranging from 1 to 4 minutes, and often, patients did not receive the intended full dose. Nausea and vomiting, known adverse events for glucagon, as well as local adverse events were most commonly reported with IN glucagon. Relevance to Patient Care and Clinical Practice: IN glucagon is safe, effective, easy to use, and does not require reconstitution prior to use, which can lead to faster delivery in a severe hypoglycemic event. It does not require age- or weight-based dosing. This delivery method offers an option for someone who fears needles or is uncomfortable with injections. Conclusion: IN glucagon is a safe, effective, easy to use, needle-free treatment option for severe hypoglycemia.

Statins for the primary prevention of cardiovascular disease in the elderly.

OBJECTIVE: The objective is to review the evidence evaluating the efficacy of statin therapy for primary prevention of cardiovascular (CV) disease in the elderly. DATA SOURCES: A literature search of MEDLINE and PubMed (1966-January 2013) using the terms HMG-CoA reductase inhibitor, statin, primary prevention, elderly, and geriatrics was performed. The search was limited to clinical trials, meta-analyses, and subanalyses, including primary prevention patients. Bibliographies of selected articles were examined to identify additional clinical trials. STUDY SELECTION: Fourteen clinical trials, subanalyses, and meta-analyses were reviewed. A total of seven clinical trials and subanalyses evaluating statin therapy versus placebo in the elderly primary prevention patients with a primary endpoint of hard coronary heart disease were included. DATA EXTRACTION: Data collected from the clinical trials and subanalyses included number of elderly patients randomized, therapy, duration of follow-up, and the incidence of coronary events. DATA SYNTHESIS: The average annual rates of first CV event increases as patients age. There is strong evidence that supports the use of statins for secondary prevention; although primary prevention, specifically in the elderly, is less defined. This paper reviews the literature specifically for primary prevention, for which the results have shown a trend toward decreased first occurrence of coronary heart disease with statin therapy in elderly patients. CONCLUSION: Statin therapy should be considered as a primary prevention therapy against coronary disease for elderly patients. Evidence-based clinical benefits are seen in this patient population. However, clinical judgment and consideration of comorbidities that may impact life expectancy should be assessed to determine appropriateness for individual patients.

Patterns of serum laboratory monitoring for safety and efficacy in patients on chronic statin therapy.

OBJECTIVE: To describe safety and efficacy laboratory monitoring of statin therapy at the University of Colorado Hospital Outpatient Clinics over a period of 3 years prior to the revised United States Food and Drug Administration statin labeling. METHODS: This retrospective, observational study evaluated serum laboratory monitoring for safety and efficacy of statin therapy between July 2008 and June 2011. Adult patients prescribed chronic statin therapy were included. The primary objective of this study was to describe the frequency of outpatient liver function tests, lipid panels, and creatine kinase for patients on chronic statin therapy. RESULTS: A total of 143 patients met study criteria. Over a 3-year period, the mean maximum frequency of measurements per patient of serum hepatic transaminases, alanine aminotransferase (ALT) and aspartate aminotransferase (AST) was higher than lipid panel measurements (5.2 ± 4.4 and 4.2 ± 2.0 respectively, p = 0.021). Only 22 of 143 patients (15.4%) had an elevation in ALT or AST. All elevations were less than three times the upper limit of normal and statin therapy was continued without changes in response to these elevations. Creatine kinase, though not a routine monitoring test, was infrequently measured (mean maximum frequency of measurements per patient 0.3 ± 0.8). CONCLUSION: Serum hepatic transaminases were routinely monitored in patients treated with chronic statin therapy. Given the absence of significant serum hepatic transaminase elevations, and clinician response to minor elevations, our data indicate that routine serum laboratory evaluations for statin toxicity are excessive.