Considerations for Treating Nonobstetric Diseases in Pregnant Patients in the Emergency Department Setting.

OBJECTIVE: To provide nonobstetric practitioners with an overview of key concepts for the pregnant patient and review treatment of 3 common acute nonobstetric diseases encountered in the emergency department setting. DATA SOURCES: A literature search of PubMed was performed (1997-February 2023) using key search terms related to pregnancy, pain, urinary tract infection (UTI), venous thromboembolism (VTE), and anticoagulants. STUDY SELECTION AND DATA EXTRACTION: Relevant articles in English and humans were considered. DATA SYNTHESIS: When caring for a pregnant patient, it is important to utilize appropriate assessments, understand terms used in this population, and recognize how the physiological and pharmacokinetic changes that occur in pregnancy can influence medication use. Pain, UTIs, and VTE are common in this population. Acetaminophen is the most widely used medication for the management of pain during pregnancy and the drug of choice for mild pain in pregnancy not responsive to nonpharmacologic treatment. Pyelonephritis is the most common nonobstetric cause of hospitalization for pregnant patients. Antimicrobial treatment should consider maternal-fetal safety and local resistance patterns. Pregnant and postpartum patients have a 4- to 5-fold increased risk of developing a VTE compared with nonpregnant patients. Low-molecular-weight heparin is the preferred treatment. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE: Pregnant patients often seek acute care in the emergency department setting for nonobstetric needs. Pharmacists in this setting should understand appropriate assessment questions and terms used within this population, the basics of physiological and pharmacokinetic changes in pregnancy that can impact treatment, and which resources are best to utilize for drug information of the pregnant patient. CONCLUSION: Practitioners in the acute care setting commonly encounter pregnant patients seeking care for nonobstetric concerns. This article covers key pregnancy-related information for the nonobstetric practitioner and focuses on the management of acute pain, UTI, and VTE during pregnancy.

The Influence of the Food and Drug Administration Pregnancy and Lactation Labeling Rule on Drug Information Resources.

BACKGROUND: Drug information resources are commonly used by health-care providers answering pregnancy-related medication questions. In 2015, the United States Food and Drug Administration approved a new pregnancy and lactation medication labeling content and format, removing the pregnancy category, and using a narrative. Despite labeling requirements changing, it is unknown if drug information resources updated monographs to reflect these changes. OBJECTIVE: The primary objective was to evaluate if commonly used drug information resources provide pregnancy information listed similar to the requirements of the Pregnancy and Lactation Labeling Rule (PLLR). Secondary analyses included evaluating the references and inclusion of the pregnancy category rating. METHODS: Pregnancy recommendations for 23 medications were evaluated in 9 drug information resources (Clinical Pharmacology, Drugs in Pregnancy and Lactation, Epocrates®, First Databank, LexiComp® Online, LexiComp® Online Pregnancy & Lactation, In-Depth, Medi-Span®, Micromedex®, and Multum®). The number of references per drug monograph and most recent reference publication year was obtained. RESULTS: LexiComp® Online Pregnancy & Lactation, In-Depth mimics the new PLLR structure and consistently had the highest number of and most recent references when the medication was included. Drugs in Pregnancy and Lactation was the next most similar in content with the PLLR and second in most references per monograph; however, the most recent reference was the textbook publication year. CONCLUSION AND RELEVANCE: LexiComp® Online Pregnancy & Lactation, In-Depth and Drugs in Pregnancy and Lactation provided pregnancy information in a format most similar to the PLLR. However, several drug information resources contained pregnancy categories ratings that were to be removed from medication labeling per the PLLR.

Evaluation of Lactation Compatibility Reference Recommendations.

Background: Multiple resources aid the interprofessional health care team when recommending medications for lactating patients. Varying degrees of breastfeeding compatibility and safety are recommended in different resources. New Food and Drug Administration labeling for lactation is being phased in to provide more consistent language in safety recommendations. Objective: The objective of this study is to evaluate lactation recommendations for select medications from different drug information resources to determine the compatibility recommendations for lactating patients. Methods: The breastfeeding recommendations for 19 medications were analyzed in 10 drug information resources. Each drug was reviewed in each resource and the published recommendations evaluated. Results:Medications and Mothers' Milk 18th Edition and LactMed had the most medications listed as compatible with breastfeeding, with Lexicomp Online, Drugs in Pregnancy and Lactation Online, and Epocrates following. LactMed stands out from the group with an average of 15.1 references per medication and number of references ranging from 0 to 58. Date ranges of references used by select resources varied. References to support recommendations ranged from 1979 to 2018 for the select resources. Conclusion and Relevance: Variation continues to exist across resources with regard to recommendations for medication safety in lactation. LactMed represents the most up-to-date and comprehensive review of literature in this review. When making decisions regarding medication use during lactation, health care professionals should consider reviewing data behind the recommendations and consulting multiple resources.

Pharmacological management of obesity in pediatric patients.

OBJECTIVE: To review current evidence of pharmacological options for managing pediatric obesity and provide potential areas for future research. DATA SOURCES: A MEDLINE search (1966 to October 2014) was conducted using the following keywords: exenatide, liraglutide, lorcaserin, metformin, obesity, orlistat, pediatric, phentermine, pramlintide, topiramate, weight loss, and zonisamide. STUDY SELECTION AND DATA EXTRACTION: Identified articles were evaluated for inclusion, with priority given to randomized controlled trials with orlistat, metformin, glucagon-like peptide-1 agonists, topiramate, and zonisamide in human subjects and articles written in English. References were also reviewed for additional trials. DATA SYNTHESIS: Whereas lifestyle modification is considered first-line therapy for obese pediatric patients, severe obesity may benefit from pharmacotherapy. Orlistat is the only Food and Drug Administration (FDA)-approved medication for pediatric obesity and reduced body mass index (BMI) by 0.5 to 4 kg/m(2), but gastrointestinal (GI) adverse effects may limit use. Metformin has demonstrated BMI reductions of 0.17 to 1.8 kg/m(2), with mild GI adverse effects usually managed with dose titration. Exenatide reduced BMI by 1.1 to 1.7 kg/m(2) and was well-tolerated with mostly transient or mild GI adverse effects. Topiramate and zonisamide reduced weight when used in the treatment of epilepsy. Future studies should examine efficacy and safety of pharmacological agents in addition to lifestyle modifications for pediatric obesity. CONCLUSIONS: Lifestyle interventions remain the treatment of choice in pediatric obesity, but concomitant pharmacotherapy may be beneficial in some patients. Orlistat should be considered as second-line therapy for pediatric obesity. Evidence suggests that other diabetes and antiepileptic medications may also provide weight-loss benefits, but safety should be further evaluated.

The Role of Consumerism in Pharmacy Education.

The notion of consumerism and that students are customers of pharmacy colleges was explored by proponents and opponents of the idea. First, a working definition of a "customer" in pharmacy education is pondered with respect to the roles and responsibilities of students and schools/colleges of pharmacy. Second, the pros and cons of "student-centered" education are considered in the light of students and their families being consumers of the educational experience. Third, the duality of student-centered education is discussed including student engagement/disengagement in their learning, professional/unprofessional behaviors, and shared/individual responsibilities. Lastly, learning and teaching environment dynamics are discerned when higher education becomes more student-centric and how that may affect the overall outcome of the student and the goals of pharmacy educational programs.

Comparison of Two Morphine Dosing Strategies in the Management of Neonatal Abstinence Syndrome.

OBJECTIVE: The incidence of neonatal abstinence syndrome (NAS) has increased in recent years. Treatment approaches usually involve opioid replacement; however, the optimal treatment strategy is unknown. This study sought to determine the impact of weight- and symptom-based morphine dosing strategies on LOS and medication exposure in patients with NAS. METHODS: A retrospective review was conducted from May 2015 to June 2017 at 2 NICUs within a health-system using different dosing approaches for NAS. Data were compared using Fisher exact tests for categorical data and t tests and Wilcoxon ranked sums for continuous data. RESULTS: Baseline demographics were well-matched except for postmenstrual age at morphine initiation (p = 0.04). The weight-based group had a larger initial morphine dose (p < 0.001) and fewer number of steps to maximum morphine dose (p = 0.009). There were no differences between groups in LOS, number of dose adjustments, doses administered, weaning steps, maximum dose, or need to re-escalate dosing. There was also no difference between the first 3 modified Finnegan scores (MFS) after transferring patients to a neonatology service. Neonates with symptom-based dosing had a higher maximum MFS (p = 0.024). Neonates in the symptom-based group required adjunct therapy more often (p < 0.0001). CONCLUSIONS: Data indicate the dosing strategy impacts number of steps to reach maximum dose and need for adjunctive therapy. Weight-based dosing may decrease the number of steps required to reach the morphine maximum dose and the need for adjunctive therapy by controlling NAS symptoms earlier.

Curricular Considerations for Preparing Student Pharmacists to Prescribe Hormonal Contraception.

In 2014, the pharmacist's role in the United States expanded to include prescribing hormonal contraception, and this practice is currently addressed by policy in 14 states and the District of Columbia. Training and education requirements for this expanded scope of practice vary between states and are changing rapidly. The objective of this review is to examine how student pharmacists are taught to provide contraceptive care, specifically for prescribing ongoing hormonal contraception and emergency contraception, and to identify potential gaps in the United States pharmacy curricula related to contraception. Despite steady adoption into community pharmacy practice, there is sparse literature assessing educational methods used to teach contraceptive care. This review offers recommendations to promote consistent and comprehensive student pharmacist education in providing contraceptive care across institutions, regardless of state policy status.

Infertility Management and Pharmacotherapy: What Every Pharmacist Should Know.

Infertility is a significant public health concern in the United States. As such, utilization of infertility services, including pharmacotherapeutic treatments, is prevalent, and the role of the pharmacist as part of the health care team is essential. Pharmacists can assist patients by providing education on infertility causes, risk factor mitigation, referrals, nonpharmacologic and pharmacologic management options, navigation of the prescription process, and resource availability for the significant financial burden accompanying infertility treatment. In-depth pharmacotherapeutic information may not be readily available to pharmacists dispensing and counseling on these medications, and infertility management regimens are often varied and complicated requiring more in-depth counseling on use and administration. Given the complexity of infertility management, pharmacists are a valuable patient support and education resource. This article provides an in-depth review of infertility management strategies, both nonpharmacologic and pharmacologic.

Pharmacists' Perspectives on Prescribing and Expanding Access to Hormonal Contraception in Pharmacies in the United States.

INTRODUCTION: Pharmacist prescribing of contraception is becoming increasingly available in selected states. The objective of this study was to assess US community pharmacists' perspectives on expanding access, barriers, and facilitators since states have begun pharmacist scope of practice expansions for prescribing contraception. METHODS: A survey study of US community pharmacists' support for expanded access models, pharmacist prescribing practices and interest, and importance of safety, cost, and professional practice issues for prescribing was conducted. RESULTS: Pharmacists are generally supportive of pharmacist prescribing and behind-the-counter models for hormonal contraception and generally opposed to over-the-counter access. A majority (65%) are interested in prescribing hormonal contraception. The top motivation for prescribing contraception is enjoying individual patient contact (94%). Safety concerns (eg, patients not obtaining health screenings) remained most important for pharmacist implementation, followed by cost (eg, lack of payment or reimbursement for pharmacists' services), and professional practice (eg, pharmacist time constraints and liability) issues. CONCLUSION: This study provides an updated understanding of attitudes toward models of expanded access to hormonal contraception, interest in prescribing, and barriers and facilitators to this service among community pharmacists. Many barriers such as time and reimbursement remain unchanged. This information can inform policy and implementation efforts.

Neonatal Herpes Simplex Viral Infections and Acyclovir: An Update.

Neonatal herpes simplex virus (HSV) infections have high morbidity and mortality rates. Optimization of treatment and prevention strategies are imperative to improve the care and outcomes of neonates infected with HSV. Management of HSV includes reducing neonatal transmission, treating acute infections, and limiting adverse neurodevelopmental outcomes and future cutaneous outbreaks after acute infections. Transmission risk may be affected by route of delivery and maternal suppressive therapy. Neonatal HSV infections are divided into 3 categories: localized skin, eyes, or mouth; localized central nervous system; or disseminated infections. Parenteral acyclovir, the pharmacologic agent of choice, is used when treating each type of infection. However, dosage strategies and durations of therapy may vary based on disease state severity, presentation, and patient characteristics. Oral acyclovir may be used as suppressive therapy after acute treatment completion in specific neonatal populations, reducing long-term adverse neurodevelopmental outcomes and future skin eruptions. The mortality rate remains high even with treatment.

Creating and Assessing Student Perception of an Examination Mastery Score Report for a Pharmacotherapy Course.

OBJECTIVE: To compare student-perceived utility of two types of score reports. METHODS: Assessment standards were followed to create a new examination score report for pharmacotherapy coursework. Student examination scores were returned using the traditional score report, the utility of which students rated along 9 dimensions. A mastery score report was also distributed, and students rated it on the same 9 dimensions. The ratings were compared to determine which the students perceived as more useful. RESULTS: The students rated the mastery score report significantly better on each of the 9 dimensions and in aggregate. CONCLUSION: Pharmacy students perceived the mastery score report as more useful in helping them improve their achievement of educational outcomes.