Real-World Evaluation of Dosing in Patients Converted From Insulin Glargine (Lantus) to Insulin Glargine (Basaglar).

Background: Basaglar, insulin glargine (BGlar; Eli Lilly, Indianapolis, IN), a follow-on biologic, was developed after the patent for Lantus, insulin glargine (LGlar; Sanofi-Aventis, Paris, France) expired. Objective: To compare the dosing and hemoglobin A1C (A1C)-lowering effects of BGlar compared with LGlar in a real-world setting. Methods: Adult patients, at 5 clinics, with type 1 (T1DM) or type 2 diabetes mellitus (T2DM) who were converted from LGlar to BGlar were included in this retrospective observational study. The primary outcome compared mean basal insulin dose (U/d) from the date of conversion to 6 months. Basal insulin and total daily insulin doses were also compared from baseline to 3- and 12-months postconversion, as also change in A1C, body weight, and estimated monthly acquisition costs of basal insulin. Results: Of the 225 patients included, 56% were male, and 81% had T2DM. The mean conversion dose (U/d) of LGlar was 46.3 ± 32.7. There was no significant difference in the mean BGlar dose (U/d) at 6 months (45.9 ± 33.5; P = 0.52), nor was there a statistical difference at 3 or 12 months. There were no significant differences in change in A1C at any time point. The estimated monthly acquisition cost of BGlar was significantly less than that for LGlar at conversion ($286 vs $341, P < 0.001) and 6 months ($290 vs $351, P < 0.001) respectively. Conclusion/Relevance: The results of this retrospective study suggest that BGlar resulted in similar glycemic outcomes compared with LGlar in a real-world setting and may be a preferable option in a value-based health care environment.

Cardiac arrest with pulseless electrical activity associated with methylphenidate in an adolescent with a normal baseline echocardiogram.

Recent concerns of adverse cardiac events associated with drugs used to treat attention-deficit-hyperactivity disorder (ADHD) have prompted debate over whether these drugs are truly safe. We describe a 17-year-old boy with a normal baseline echocardiogram who had been taking methylphenidate for ADHD for 18 months and experienced cardiac arrest. Emergency personnel attempted to resuscitate him, performing defibrillation twice for ventricular fibrillation, with subsequent pulseless electrical activity. The patient was immediately taken to the hospital where he received continued resuscitation, intravenous boluses of cardiac drugs, and additional defibrillation. A persistent pulsatile rhythm returned about 2 minutes after arrival. Overall, the patient was pulseless for 22 minutes. Emergency cardiac catheterization revealed wall motion abnormalities without coronary lesions. He was mechanically ventilated and was transferred to the intensive care unit, where he remained comatose. Neurologic studies performed the next day revealed diffuse encephalopathy due to anoxic brain injury. An echocardiogram on day 3 showed slightly improved left ventricular systolic function, which improved further by day 15. As the patient did not regain purposeful movement, he was discharged to a rehabilitation facility on day 33. The patient's methylphenidate therapy had been started at an appropriate dose of 18 mg/day and titrated over a period of 3 months up to 36 mg/day, which he continued until the event. The drug had been discontinued on admission, was not restarted, and for the next 2 years, the patient experienced no further cardiac events, although his severe mental deficiencies persisted. Use of the Naranjo adverse drug reaction probability scale indicated a probable relationship (score of 6) between the patient's adverse cardiac event and methylphenidate. To our knowledge, this is the first case report of a patient with documentation of a normal baseline echocardiogram who experienced cardiac arrest with pulseless electrical activity while taking methylphenidate for ADHD. Clinicians should be aware that despite performing a comprehensive cardiac examination before prescribing a stimulant for ADHD, patients may still be at risk for a serious cardiac event. The risks and benefits of using these drugs must be assessed by clinicians, parents, and patients.

Tigecycline for treatment of pneumonia and empyema caused by carbapenemase-producing Klebsiella pneumoniae.

Strains of Klebsiella pneumoniae that produce one of three possible carbapenemases--KPC--have recently been identified with increasing frequency among isolates recovered from patients residing along the East Coast of the United States, particularly within the New York City metropolitan region. These strains have exhibited resistance to multiple antibiotic classes, including carbapenem agents. We report a case of nosocomial pneumonia and empyema caused by a KPC-producing isolate of K. pneumoniae at a large midwestern U.S. tertiary care facility in which the patient was treated with tigecycline. Although the pneumonia was treated successfully, the empyema recurred in association with a treatment-emergent tigecycline minimum inhibitory concentration (MIC) increase from 0.75 to 2 microg/ml. Clinicians should be aware of the potential occurrence of this treatment-emergent MIC increase, especially in the setting of sustained tigecycline therapy. In addition, the emergence of carbapenem-resistant Enterobacteriaceae reinforces the importance of antibiotic stewardship and strict infection control practices.

Evaluation of dabigatran for appropriateness of use and bleeding events in a community hospital setting.

BACKGROUND: Warfarin has been the predominant anticoagulant for the prevention of stroke and systemic embolism in patients with nonvalvular atrial fibrillation (NVAF). Its disadvantages are well-known and include a narrow therapeutic index, drug interactions, and the need for frequent monitoring. Dabigatran etexilate, a direct thrombin inhibitor, presents less complexity in prescribing and has emerged as an alternate therapy to warfarin. Although dabigatran does not require routine monitoring, concerns associated with its use include the lack of a reversal agent, complex dose adjustments, and limited guidance to the management of drug interactions. OBJECTIVES: The goals of this study are to describe and to evaluate the use of dabigatran at a community hospital to identify areas for improvement in its prescribing. METHODS: This retrospective chart review of patients at a community hospital in St Louis, MO, included patients who received at least 1 dose of dabigatran between December 2010 and June 2012. The appropriateness of dabigatran was evaluated based on recommendations approved by the US Food and Drug Administration for stroke prophylaxis in the setting of NVAF. The composite end point of bleeding included hospital readmission within 1 year of receiving at least 1 dose of dabigatran at the study institution secondary to bleeding, bleeding associated with a decrease in hemoglobin level by ≥2 g/dL or transfusion of ≥2 units of blood, or a notation of bleeding in the patient's medical record. RESULTS: Of the 458 patients included in the evaluation, 76 (16.6%) patients receiving dabigatran were using an inappropriate regimen of this drug, based on dose and frequency on the first day of therapy of dabigatran or the presence of valvular disease. Many patients (42.3%) received at least 1 dose of a concomitant parenteral anticoagulant. The composite end point for bleeding was reported in 66 (14.4%) patients, including 23 (5%) with confirmed gastrointestinal bleeding. CONCLUSIONS: High-risk medications such as dabigatran require monitoring of prescribing habits to improve patient safety and outcomes. Various initiatives, such as pharmacist interventions, therapeutic interchanges, and obtaining appropriate patient parameters, can be implemented in the practice setting to ensure the appropriate use of oral anticoagulants and improved patient outcomes.

Impact of a student-supported pharmacy assessment program on venous thromboembolism prophylaxis rates in hospitalized patients.

OBJECTIVES: To determine if the addition of a student-supported venous thromboembolism risk assessment strategy could improve rates of venous thromboembolism prophylaxis at a community teaching hospital. METHODS: After receiving education and training on venous thromboembolism risk assessment, students assessed patients and recommended therapy in a 493-bed community teaching hospital over 5 weeks. Both the quantity and quality of venous thromboembolism prophylaxis were measured and compared to a baseline rate. RESULTS: One hundred three recommendations were made to physicians with a 41% acceptance rate. Compared to previous rates, the percentages of patients receiving "any," "suitable," and "optimal" venous thromboembolism prophylaxis increased from 70.5% to 82.7% (p = 0.0005), 64.4% to 75.9% (p = 0.0022), and 56.3% to 68.5% (p = 0.0022), respectively. CONCLUSIONS: A student-supported venous thromboembolism risk assessment strategy resulted in an increase in venous thromboembolism prophylaxis rates and could be used as a model for other institutions to integrate students into population-based care.