Geriatric Pharmacotherapy Case Series: Potential Drug Interactions With Antiplatelet Medications and Cannabidiol-A Focus on P2Y12 Inhibitors.

Background A 76-year-old man was admitted to a local rehabilitation inpatient facility following an acute myocardial infarction. Patient history included hypertension and previous stroke. The patient was being treated with clopidogrel and aspirin for secondary stroke prevention along with other medications to treat hypertension. The patient admitted to using cannabidiol (CBD) oil up to three times a day for knee pain prior to acute myocardial infarction and requested to continue its use in the facility. Assessment Prior to this hospital stay, the patient was able to continue activities of daily living with knee pain that was controlled by CBD oil used three times daily. The option to continue CBD oil would create a possible drug interaction with current cardiovascular medications leading to increased cardiovascular or bleeding risks. Outcome The patient was advised against the use of CBD products because of potential interaction with clopidogrel and was prescribed acetaminophen for osteoarthritis (knee pain). The patient continued to improve and was discharged to his home after two weeks of rehabilitation. Conclusion Based on limited pharmacodynamic and pharmacokinetic studies in older people, patients should avoid using cannabidiol and products containing its derivatives with P2Y12 inhibitors. A potential interaction between cannabidiol and its derivatives with P2Y12 inhibitors may increase a patient's cardiovascular or bleeding risks. Patients and health care providers must be adequately informed about potential risks associated with cannabidiol products and oral antiplatelets to prevent negative outcomes.

Potential Drug Interactions Between Cannabinoids and Its Derivatives and Oral Anticoagulants.

The increase use of cannabidiol containing products poses potential risks with high-alert medications such as oral anticoagulants. To review the use of cannabidiol and its' derivatives with oral anticoagulants, searches (2005-May 2020) were performed by PubMed, Google Scholar, and ClinicalTrials.gov. Articles were limited to English-language only. The results yielded 4 case reports evaluating the potential drug interactions between cannabinoids and its' derivatives and oral anticoagulants. These case reports show the potential for drug interactions when using warfarin and cannabidiol containing products. At time of publication, there were no published articles on drug interactions between cannabidiol and the direct oral anticoagulants. Further research is needed to conclude drug interactions are associated with an increased risk of bleeding or thromboembolic events in these patients.

Faith Integration in the Development of an Interprofessional Education Faculty Fellowship.

To cultivate faculty facilitators in interprofessional education, a college of health sciences at a Christian university established a fellowship for interprofessional development that incorporated faith-based activities. Twenty-eight faculty formed nine interprofessional project groups that participated in the 12-month fellowship across two academic years. The objective was to gain competence in interprofessional education. Analysis of pre- and postassessment findings revealed a statistically significant difference between the two assessments in seeking information related to faith-based aspects of care. This educational intervention suggests that the inclusion of a faith component may help to shift faculty perceptions of faith-based care during development of interprofessional education opportunities.

Extended-Duration Use of Direct Oral Anticoagulants to Prevent VTE in Acutely III Medical Patients.

OBJECTIVE: To evaluate current clinical evidence for the use of direct oral anticoagulants (DOACs) for extended-duration thromboprophylaxis in the acutely ill medical population for venous thromboembolism (VTE) and bleeding events.
DATA SOURCES: Were obtained through a MEDLINE/PubMed search for clinical trials conducted from March 2008 to 2018 using relevant key words. Limitations of English and human subjects were applied to search results.
STUDY SELECTION AND DATA EXTRACTION: Forty-one articles were identified, and abstracts reviewed by the authors for inclusion of the study population (acutely ill medical patients) and VTE outcomes. Clinical studies evaluating the use of DOACs for extended duration of VTE prevention in acutely ill medical patients were included in the review, resulting in three clinical trials and two subgroup analyses. The participants enrolled had an overall mean age of 71.4 years.
DATA SYNTHESIS: The DOAC trials collectively demonstrated a positive outcome in composite endpoints of VTE prevention with extended-duration thromboprophylaxis in acutely ill medical patients compared with enoxaparin. As for safety, rivaroxaban and apixaban trials reported more major bleeding events compared with enoxaparin. The betrixaban trial demonstrated no difference in bleeding compared with enoxaparin.
CONCLUSION: DOACs reduced the number of VTE events in acutely ill medical patients on extended-duration thromboprophylaxis, but with an overall increased bleeding risk. An individualized patient approach based on risk factors should be utilized for treatment with extended-duration DOAC in the older adult population with recent hospitalization.

Intentional Interprofessional Experiential Education.

The experiential component of a doctor of pharmacy curricula is an ideal, yet underutilized vehicle to advance interprofessional education (IPE) initiatives. To date, most experiential-based IPE initiatives occur in a naturally occurring, non-deliberate fashion. The American Association of Colleges of Pharmacy (AACP) Experiential Education Section formed the Task Force on Intentional Interprofessional Education in Experiential Education in academic year 2015-2016 to explore the issue. This commentary describes the work of the task force, including the following elements: defining intentional interprofessional experiential education as "the explicit effort by preceptors and practice sites to create/foster educational opportunities or activities designed specifically to achieve interprofessional educational competencies;" conducting a systematic literature review to identify examples of intentional interprofessional experiential education in the published literature; surveying faculty with oversight of experiential education programs and preceptors within those programs; and generating recommendations to stakeholders including AACP, pharmacy schools, and experiential education administrators.

Betrixaban (Bevyxxa): A Direct-Acting Oral Anticoagulant Factor Xa Inhibitor.

Betrixaban (Bevyxxa): a direct-acting oral anti-coagulant factor Xa inhibitor.

Use of a Video Module to Improve Faculty Understanding of the Pharmacists' Patient Care Process.

OBJECTIVE: To evaluate change in faculty's knowledge and perceptions after an online video module on the Pharmacists' Patient Care Process (PPCP). INNOVATION: An educational video module on the PPCP was developed and disseminated to full-time faculty members at Samford University, McWhorter School of Pharmacy. Voluntary and anonymous pre- and post-test assessments were evaluated and analyzed. CRITICAL ANALYSIS: Thirty faculty completed the pre-assessment, and 31 completed the post-assessment (73% and 75% response rates, respectively). A significant improvement in faculty perceptions was indicated by an increase in agreement with the majority (80%) of questions on attitudes toward the PPCP on the post-test. Faculty's knowledge of the introduction and assessment of PPCP within the school's curriculum was significantly increased after viewing the video module. After viewing the module, more faculty were also able to correctly identify the majority of the PPCP components and their corresponding practice activities. NEXT STEPS: A short video module was effective at improving faculty knowledge and perceptions of the PPCP. Development of a similar faculty development module is feasible for implementation in other Schools of Pharmacy.

The use of direct oral anticoagulants in inherited thrombophilia.

To review the use of the direct oral anticoagulant (DOAC) agents in inherited thrombophilia based on the literature. MEDLINE, International Pharmaceutical Abstracts, and Google Scholar searches (1970-May 2016) were conducted for case reports, case series, retrospective cohorts, or clinical trials using the key words: protein C deficiency, protein S deficiency, antithrombin deficiency, activated protein C resistance, Factor V Leiden, hypercoagulable, NOACs, dabigatran, apixaban, rivaroxaban, betrixaban, edoxaban, Xa inhibitor, direct thrombin inhibitor. Results were limited to English-only articles. Clinical studies evaluating the use of DOACs for hypercoagulable states related to inherited thrombophilia were selected and evaluated. Thrombophilia, a predisposition to thrombosis, manifests predominantly as venous thromboembolism. Causes of inherited thrombophilia include antithrombin deficiency, deficiencies of proteins C and S, and Factor V Leiden mutation. Many patients with thrombophilia receive anticoagulant therapy for primary or secondary prevention of VTE, historically either warfarin or a heparin product. DOAC's have been considered as potential alternatives to traditional agents based on their pharmacologic activity. Case reports and a post-hoc analysis of a clinical trial have indicated positive results in patients with inherited thrombophilia and VTE. Positive results have been reported for the use of DOACs in inherited thrombophilia. Further robust studies are needed for definitive decision making by clinicians.

Role of Novel Oral Anticoagulants in the Treatment of Antiphospholipid Syndrome.

Background: Antiphospholipid syndrome (APS) is an autoimmune disease characterized by thrombosis or pregnancy loss with persistent positive antibodies. Standard treatment for APS with history of thromboembolism is heparin or low-molecular-weight heparin followed by a vitamin K antagonist (VKA). Novel oral anticoagulants (NOACs) could be effective in patients with APS, but none carry indications for treatment related to APS. Clinical Evidence: Five case reports or series with rivaroxaban and dabigatran suggest thrombotic events occur most often in the higher risk population (arterial thrombosis and/or triple positive antibodies) or in patients who had recurrent VTEs on warfarin therapy. An observational cohort in 26 APS patients using dabigatran or rivaroxaban described a recurrent thrombotic event in only 1 patient after 8 months of treatment. The event-free survival rate was 87.9% at 12 months. Three controlled clinical trials are underway to evaluate the thrombotic risk of NOACs (RAPS, TRAPS, and ASTRO-APS). Discussion: There are no completed studies that evaluate the use of NOACs in APS compared to VKAs. One major disadvantage of the NOACs is the limited availability of reversal agents for patients with a major bleeding episode. An increased risk of thrombotic events is associated with arterial occlusions and triple antibody positivity APS with both warfarin and NOACs; this is currently being researched in the TRAPS study. Conclusion: Based on current available evidence, VKAs remain the standard of care in the treatment of APS. Results of ongoing trials may offer more guidance on how to appropriately use NOACs for patients with APS.

Recurrent venous thromboembolism in a patient with heterozygous factor v leiden mutation.

OBJECTIVE: To report a patient case identifying risk for recurrent venous thromboembolism (VTE) associated with heterozygous Factor V Leiden mutation. CASE SUMMARY: A 54-year-old Caucasian male was diagnosed with heterozygous Factor V Leiden mutation in 2008 after experiencing a deep vein thrombosis (DVT) and bilateral pulmonary embolism. The patient was treated appropriately and started on anticoagulation therapy with warfarin through an anticoagulation management clinic. After approximately 17 months of warfarin therapy without incident, warfarin was discontinued. Within 2 months after discontinuation of anticoagulation therapy, the patient experienced his second DVT and left pulmonary artery embolus. DISCUSSION: The risk of recurrent venous thromboembolism (VTE) in patients with heterozygous Factor V Leiden mutation is documented as an approximate 1.4-fold increase compared to patients without thrombophilia. However, the risk increases dramatically when nonreversible (age) or reversible risk factors (obesity, smoking, and long air flights) are present in this population. CONCLUSION: Based on recent literature, heterozygous Factor V Leiden mutation exponentially increases the risk of recurrent VTE, especially in the presence of other risk factors. Health care providers should complete a comprehensive review of the patients' other risk factors when deciding on duration of anticoagulation therapy for patients with positive heterozygous Factor V Leiden mutation.

Vilazodone for the treatment of major depressive disorder.

Major depressive disorder (MDD) affects 121 million people globally and is one of the leading causes of functional disability worldwide. As a recurrent disorder, MDD is associated with significant morbidity and functional disability as well as high direct and indirect costs to the health care system. Although several drug therapies are available for treating MDD, many patients do not achieve a sustained remission. Vilazodone was approved by the United States Food and Drug Administration in 2011 and has a distinctive pharmacology profile, as the drug is a selective serotonin reuptake inhibitor and serotonin 5-HT(1A) receptor partial agonist. In two 8-week, double-blind, placebo-controlled trials, vilazodone's overall rate of response was similar to other antidepressants for the treatment of MDD. Compared with placebo, remission rates were not significantly different in one trial and were not reported in the second trial. Vilazodone was generally well tolerated, with nausea and diarrhea being the most frequent adverse events reported. Postmarketing studies and further active comparative studies will provide additional insight to the potential benefits and safety of this novel drug.

Pharmacists' advancing roles in drug and disease management: a review of states' legislation.

OBJECTIVES: To determine which states in the United States have provisions in place for pharmacist participation in drug and disease management programs and/or collaborative practice agreements and to provide comparison and discussion regarding such provisions. A secondary endpoint was the requirements of certification, credentialing, and registration with the specific state's rules and regulations. DATA SOURCES: Information was gathered from states' statutes, rules, and regulations. Acquisition of each state's laws was achieved through various forms of electronic media. Data were accessed from January to March 2008. DATA SYNTHESIS: 19 states (38%) had specific provisions for disease management, 33 (66%) had provisions for drug therapy management, and 37 (74%) had provisions for collaborative practice. A total of 11 states (22%) specified that pharmacists receive specialized training to participate in such endeavors. Board approval or notification for collaborative practice agreements was required in 16 states (32%). CONCLUSION: With varying degrees of autonomy and restriction, pharmacists in certain states have the ability to develop disease management and/or collaborative practice programs. For pharmacists to take advantage of these new direct patient care opportunities, knowing the rules and requirements of their state's legislation is essential.