Use of Sodium-Glucose Cotransporter-2 Inhibitor for Diabetes Management in Patients Following Kidney Transplantation.

Objective: To evaluate data sources pertaining to the safety and efficacy of sodium-glucose cotransporter-2 (SGLT2) inhibitor use for diabetes management in patients following kidney transplantation. Data Sources: A literature search was conducted through PubMed (1966-January 2023), EMBASE (1973-January 2023), and clinicaltrials.gov databases using the search terms kidney transplantation, diabetes mellitus, and SGLT2 inhibitor or empagliflozin, dapagliflozin, and canagliflozin. Study Selection and Data Extraction: Studies evaluating human kidney transplant recipients (KTR) receiving SGLT2 inhibitors treatment and published in the English language were included. Eight case series or retrospective analyses, 4 prospective observational studies, and 1 randomized controlled trial were identified. Data Synthesis: Available literature provides evidence that the addition of SGLT2 inhibitors may provide modest benefits on glycemic control, body weight, and serum uric acid levels in certain KTR. Various studies and case reports found that incidence of urinary tract infections was low, but still present. Overall, there are limited data on mortality and graft survival; however, one study reported a benefit of SGLT2 inhibitor use in KTR relative to these outcomes. Conclusions: The current literature evaluated demonstrates that there may be benefit to the addition of SGLT2 inhibitors for diabetes management in select KTR. However, the limited evidence within a large diverse population and extended duration of treatment makes it difficult to definitively identify the true efficacy and safety of SGLT2 inhibitor use in this population.

Examination of the Effectiveness of Direct Oral Anticoagulants in Comparison to Warfarin in an Obese Population.

Background: While commonly prescribed today, direct oral anticoagulants (DOACs) have historically been avoided in patients with class III obesity or a weight >120 kg due to limited literature regarding the efficacy and safety in this population. Objective: The overall objective was to examine the effectiveness of DOACs compared to warfarin in a population with obesity. Methods: Patients with a diagnosis of venous thromboembolism (VTE) or atrial fibrillation and a body mass index (BMI) ≥35 kg/m2 from August 1, 2015, to August 1, 2020, were included in this retrospective cohort study. Patients receiving a DOAC were matched in a 1:2 ratio to warfarin. The primary outcome was a composite of stroke or recurrent VTE. Secondary outcomes included the individual components of the primary outcome, hospitalization for bleed, and the primary outcome in patients with a BMI ≥40 kg/m2. Results: A total of 162 patients were included, with 54 and 108 in the DOAC and warfarin groups, respectively. Baseline BMI was similar between groups (45.7 kg/m2 for DOACs vs 43.8 kg/m2 for warfarin), with approximately 70% of patients having a BMI ≥40 kg/m2. The primary outcome occurred in 1 patient (1.9%) in the DOAC group and 2 patients (1.9%) in the warfarin group. The DOAC group had a higher, nonsignificant incidence of bleeding (5.6% vs 0.9%, P = 0.11). There was no difference between groups in incidence of deep vein thrombosis (DVT), pulmonary embolism (PE), or stroke in patients with a BMI ≥40 kg/m2. Conclusion: DOACs may be as efficacious as warfarin in the prevention of stroke or recurrent VTE in patients with a BMI of ≥35 kg/m2. Prospective, randomized trials are warranted to further assess the efficacy and safety of DOACs in this population.

Implementation of a Discharge Education Program to Improve Transitions of Care for Patients at High Risk of Medication Errors.

Background: Transitions of care (TOC) points are those where patient outcomes can be affected, especially patients at high risk for medication errors. Pharmacist-led postdischarge telephone counseling positively affects patient outcomes, though challenges exist relating to successful patient contact. Objective: The objective of this study was to develop and evaluate a discharge education service bridging the inpatient and outpatient setting to increase successful patient contact points during the TOC process from hospital to home. Methods: This prospective, single-centered observational study examined the impact of a discharge medication education program on successful telephone follow-up contact. The primary outcome was the percentage of high-risk patients educated at hospital discharge who were successfully reached via follow-up telephone contact within 2 business days of discharge. Secondary end points included hospital readmission rates and patient survey responses. Results: A total of 50 patients were included in the initial evaluation of this service; 78% of patients were successfully contacted within 2 business days after discharge, an increase from a 20% success rate prior to service implementation. At follow-up telephone calls, patients reported taking an average of 16 medications. The 30-day readmission rate was 10% for patients receiving this service, compared with 19% prior to implementation. When asked if they understood the medication component of their care and if they found the TOC service to be satisfactory, 100% and 96% of patients strongly agreed or agreed with these statements, respectively, and none disagreed. Conclusion and Relevance: This service demonstrates how pharmacists can interact with a high-risk population and increase contact points to optimize care at crucial health care transition points.

Impact of Point-of-Care Implementation in Pharmacist-Run Anticoagulation Clinics Within a Community-Owned Health System: A Two-Year Retrospective Analysis.

BACKGROUND: Point-of-care (POC) testing devices allow laboratory monitoring to be performed in various settings and accessed immediately. OBJECTIVE: To evaluate the outcomes of monitoring anticoagulation patients in pharmacistmanaged, multicenter clinics utilizing i-STAT POC machines. METHODS: This study was a retrospective, multicenter chart review of 150 patients before and after implementation of the POC intervention for anticoagulation monitoring. Data collected included international normalized ratio (INR) results, indication for warfarin, minor and major bleeds, thromboembolic events, emergency room (ER) visits, and hospitalizations before and after i-STAT POC implementation. RESULTS: The time in therapeutic INR range (TTR) was significantly higher after i-STAT POC implementation than before implementation (60.4% ± 21.2% and 52.5% ± 21.5%, respectively; P = .0001). There were no reports of major bleeding during the study period. Twenty-three minor bleeds were reported after i-STAT POC implementation compared to 19 events before implementation (P < .0001). One thromboembolic event was reported after i-STAT POC implementation. There was a significant difference in the number of hospitalizations before i-STAT POC implementation as opposed to after implementation (2 and 0, respectively; P < .0001). There was also a significant increase in ER visits after i-STAT POC implementation (P < .0001). CONCLUSION: The results of the study indicate improvement in TTR in pharmacist-managed anticoagulation clinics by 7.8%. Although the use of the i-STAT POC machine detected an increase in minor bleeds, thromboembolic events, and ER visits, there was a decrease in hospitalization. The outcomes of this multicenter study indicate that implementation on this scale provides improvement in regard to safety and cost.

Association between prescription drug benefit and hospital readmission rates.

PURPOSE: To determine whether primary care medicine clinic (PCMC) patients with a prescription drug benefit were associated with a lower rate of hospital readmissions. METHODS: This study was a retrospective, single-center, cohort study of PCMC patients who had at least 1 hospital readmission in 2011. Eligible patients were divided into 2 groups: patients without prescription drug benefits and patients with prescription drug benefits. RESULTS: Three hundred fifty-two patients met our inclusion criteria. The number of hospital readmissions for patients with a prescription drug benefit was higher than those with no prescription drug benefit (2.453 ± 2.49 vs 1.88 ± 1.91; P = .052). The length of index admission and the length of hospital readmission in days were higher in patients with no prescription drug benefits (index admission, 5.29 ± 6.38 vs 4.59 ± 4.50; P = .428) (readmission, 5.31 ± 5.90 vs 4.48 ± 4.33, P = .166). The number of days to readmission was higher in those with drug benefits (58.12 ± 63.54 vs 53.39 ± 53.47; P = .316). When patient data were separated by CCI scores, it was noted that patients with pharmacy benefits had significantly more hospital readmissions in each CCI score category except for patients with a CCI of 6. CONCLUSION: Although not statistically significant, patients with prescription drug benefits had more hospital readmissions but shorter hospital lengths of stay. Significant data linking hospital readmissions and prescription insurance benefits, if found in future studies, would provide helpful guidance to health care systems.

Assessing the utility of pre-course assessment and voluntary pre-work in two required integrated pharmacotherapy courses.

BACKGROUND AND PURPOSE: Self-assessment and self-learning are essential skills for student pharmacists. Data demonstrating the association between these skills in pharmacy courses are limited. The aim of this study was to evaluate the impact of providing pre-course review and administering a pre-course assessment on performance in two required integrated pharmacotherapy (IP) courses - IP: Pulmonology and IP: Cardiology. EDUCATIONAL ACTIVITY AND SETTING: This study included second-year student pharmacists enrolled in fall semester IP: Pulmonology and IP: Cardiology from 2019 to 2021. Voluntary pre-course review materials and pre-course assessments were added in fall 2021. Overall course grades and examination scores between each year were analyzed. Student perceptions of the pre-course assessment were also captured. FINDINGS: Of the 454 students analyzed, there was no difference in median overall IP: Pulmonology grades (85.93%, 86.67%, 86.29%; P = .63) or IP: Cardiology grades (80.25%, 78.3%, 79.96%; P = .41) for 2019, 2020, and 2021, respectively. IP: Pulmonology Exam 1 scores were statistically higher in 2021. For IP: Cardiology, Exam 1 and Final Exam scores were statistically higher in 2020 compared to 2019 and Exam 3 scores were significantly higher in 2021 than 2019. Pre-course assessment scores had a statistically significant, positive association with overall course grade. Half of the students surveyed agreed that completing the course prep work was an effective approach to learning. SUMMARY: Although overall course grades did not differ between years, pre-course assessment scores correlated with overall course grade. Thus, voluntary pre-course assessments could provide early identification of poor performance.

The Impact of a Clinical Pharmacist in an Interdisciplinary Weight Loss Service: A Follow-Up Study.

Background: At an Internal Medicine outpatient clinic, patients are referred to a weight loss service by their primary care physician to be managed by a clinical pharmacist and dietician. Objective: A study was conducted to determine the impact of this established, interdisciplinary, pharmacist-driven weight loss service on percent weight loss from baseline in patients who are obese or overweight compared to those receiving standard weight loss care. Methods: This was a retrospective, single-center, cohort study including adults ≥18 years of age with BMI ≥30 or BMI ≥27 with at least one weight-related comorbidity such as hypertension, dyslipidemia, or type 2 diabetes mellitus, and referred to the clinic's weight loss service or managed by their primary care physician. The primary outcome was percent weight loss from baseline. Key secondary outcomes included number of patients who had >5% weight loss in 6 months, number of patients who received liraglutide after 6 months, and percent weight loss in patients prescribed liraglutide. Statistical analysis included descriptive statistics, t-test for continuous outcomes, and chi-square test for between-group differences. Results: A total of 86 patients met inclusion criteria with 43 patients in the weight loss service group (intervention) and 43 patients in the primary care group (standard care). The intervention group had a significantly higher baseline weight and BMI than the standard care group (120.44 kg vs. 95.72 kg, p <0.001 and 45.34 kg/m2 vs. 37.62 kg/m2, p <0.001 respectively). The percent change in weight from baseline in the intervention group was a decrease of 3% compared to a decrease of 0.35% in the standard care group (p=0.03). Conclusions: Involvement of clinical pharmacist in interdisciplinary weight loss management through pharmacotherapy and other medication related services, shows considerable improvement in weight loss, when compared to the standard care of weight management. However, prospective randomized studies are warranted to further assess the benefits of a pharmacist-driven, interdisciplinary weight loss service.

Impact of an electronic-based assessment on student pharmacist performance in a required therapeutics course.

INTRODUCTION: The use of technology in the classroom has continued to grow, and with the advancement of classroom management systems and online exam software, there are opportunities to administer exams electronically. This study assessed the impact of electronic-based assessments on examination scores in a required therapeutics course. METHODS: This was a retrospective, single-centered, observational study including second professional year pharmacy students enrolled in a required, one semester therapeutics course. Four assessments were administered each semester. Lecture content and exam format, a mixture of multiple-choice questions and free response written cases, did not differ significantly between years. Assessments administered during the first two years were printed on paper, while assessments administered during the third and fourth year of the study were all electronic, submitted through a classroom management system. Following institutional review board approval, the change in mean overall examination scores between paper and electronic-based assessments were analyzed. RESULTS: Of the 948 students enrolled in this study, there was no difference in overall mean scores between paper and electronic-based assessments (74.8% vs. 73.8%). In addition, there was no difference in mean examination scores between overall individual paper and electronic Exam 1 through 4 or overall multiple-choice or free response scores between paper and electronic-based assessments. CONCLUSIONS: Scores did not differ between paper and electronic-based assessments. From this study, test method does not appear to impact exam results.

Incorporating an internet-based voicemail drug information assessment in an introductory pharmacy practice course.

OBJECTIVES: To examine the implementation and student perceptions of an innovative verbal drug information assessment. DESIGN: The drug information assignment in an introductory pharmacy practice course was redesigned and an assessment of a verbal response to a drug information request was added with the use of an internet-based voicemail (IBVM) system. ASSESSMENT: Students performed well on both the verbal vs. written assessments. Most students strongly agreed or agreed that completing both assignments was a valuable experience; however, more students agreed that the verbal assignment was useful (90% vs. 83%). More students agreed that the verbal assignment helped prepare them as a pharmacist (97% vs. 85%) and that the verbal assignment increased their confidence (82% vs. 78%). Student comments echoed these results; additionally, many indicated that the verbal assessment was realistic. CONCLUSION: The IBVM assessment was successful, user-friendly, and this mode of assessment may be useful in other courses.

Diabetes Outcomes: Comparison of Patient Assistance Programs to 340B Drug Pricing.

BACKGROUND: Patient assistance programs (PAPs) or obtaining 340B drug pricing offers a means of providing medications at low cost. The purpose of this study was to determine whether primary care patients who receive insulin from PAPs have an improved change in A1C, compared to 340B patients. METHODS: This was a retrospective study of primary care patients who obtained insulin therapy through a PAP or 340B between June 1, 2012, and June 1, 2013. RESULTS: The baseline and change in A1C for PAP patients was similar to 340B patients (10.3% vs. 9.3%) (-0.52 ±2.67 vs. -0.3 ±2.32, p=.66). Baseline and changes in SCr (1.0 vs. 0.99) (0.08 ±0.26 vs. 0.08 ±0.40, p=.93) and BMI (34.0 vs. 33.9) (0.15 ±2.29 vs. 0.10 ±2.16, p=.89) were also similar. PDC values averaged 0.74 in PAP patients, and 0.72 in 340B patients (p=.93). CONCLUSION: This study may serve as a platform for future research.