Journal of Pharmacy Technology

Includes bibliogprahical references.

Creating Meaningful Alerts and Reducing Alert Fatigue: Strategies Implemented by Informatics Pharmacists to Optimize Dose Range Checking Alerts in a Multihospital Health System -- Ceftriaxone 1 g Versus 2 g Daily for the Treatment of Enterobacterales Bacteremia: A Retrospective Cohort Study -- Interprofessional Collaboration Between a Clinical Pharmacist and Specialty Physicians to Treat Hepatitis C in an Interdisciplinary Medical Practice Setting -- Tricyclic Antidepressant Overdose Manikin Simulation in Student Pharmacists -- Drug Interactions Associated With Therapies for Pulmonary Arterial Hypertension -- Complications of Corticosteroid Therapy: A Comprehensive Literature Review -- Setmelanotide: A Novel Targeted Treatment for Monogenic Obesity -- Enhanced Anticoagulant Effect of Warfarin When Co-administered With Quercetin -- Pharmacists’ Perceptions About the Effect of Work Environment Factors on Patient Safety in Large-Chain Retail Pharmacies.

[Article Title: Creating Meaningful Alerts and Reducing Alert Fatigue: Strategies Implemented by Informatics Pharmacists to Optimize Dose Range Checking Alerts in a Multihospital Health System/ Jonathan F. Choukroun, Kristina Leeand Aixa Rey, p. 319-325]

Abstract:

Background: Among the many clinical decision support (CDS) mechanisms available in electronic health record (EHR) systems, dose range checking (DRC) is one of the most impactful safeguard tools integrated within most computerized provider order entry (CPOE) workflows. Unfortunately, improper configurations and lack of resources to maintain and monitor CDS systems can hinder and even disrupt daily clinical operations.

Objective: This article seeks to highlight the impact that informatics pharmacists can make by implementing different strategies to decrease nuisance alerts and create clinically meaningful DRC alerts that guide clinicians in their practice.

Methods: Following the activation of the DRC application for 3623 medication groupers (ie, generic drugs and all their dosage form variations), informatics pharmacists implemented strategies to monitor DRC alert output and decrease the number of inappropriate alerts. Such strategies included weekly monitoring of alerts, modification of order sentences (including dose, route, and age/weight filters), update to the rule triggering the alerts, and modifications of the preference settings.

Results: From July to September 2018, an average of 70 DRC tables were reviewed by informatics pharmacists, reducing the number of overridden DRC alerts to 4796 in the first week of September—a 63% decrease in a 3-month period.

Conclusions: By reducing the number of DRC nuisance alerts and improving the clinical content of DRC alerts, informatics pharmacists can contribute to lowering alert fatigue and improving providers’ trust in CDS alerts.

https://doi.org/10.1177/87551225221117152

[Article Title: Ceftriaxone 1 g Versus 2 g Daily for the Treatment of Enterobacterales Bacteremia: A Retrospective Cohort Study/ Nadeem Baalbaki, Sharon Blum, Meredith Akerman and Diane Johnson, p. 326–334]

Abstract:

Background: Ceftriaxone is a commonly used antibiotic for the treatment of susceptible Enterobacterales infections. There is currently limited clinical data on the optimal dose of ceftriaxone for Enterobacterales bacteremia.

Objectives: To evaluate the rate of clinical failure of ceftriaxone 1 g versus 2 g daily in patients with Enterobacterales bacteremia.

Methods: This was a retrospective cohort study of patients admitted to any of the 3 New York University Hospitals: Long Island, Tisch, or Brooklyn, with ceftriaxone-susceptible Enterobacterales bacteremia, receiving ceftriaxone 1 or 2 g daily from October 2019 to September 2020. The primary outcome was 90-day rate of clinical failure. Clinical failure was defined as escalation of therapy, relapse of infection, or all-cause mortality.

Results: A total of 124 patients, 58% in the 1-g group and 42% in the 2-g group, were included. There was no statistically significant difference found in the primary outcome. The 90-day rate of clinical failure was 16.7% versus 9.6%, P = 0.260. There were no statistically significant secondary outcomes, although infection relapse rates at 90 days were numerically greater in the 1-g group (11.1% vs 1.9%, P = 0.078). Hypoalbuminemia was the only variable associated with an increased risk of clinical failure (odds ratio = 4.03; 95% confidence interval [CI] = 1.12-14.50, P = 0.033).

Conclusion: In our exploratory findings, there was no statistically significant difference with the 90-day rate of clinical failure between ceftriaxone 1 g versus 2 g daily, although there was a numeric trend toward an increased rate of infection relapse within the 1-g group. Hypoalbuminemia was associated with an increased risk of clinical failure. Prospective studies are warranted to confirm these findings.

https://doi.org/10.1177/87551225221121252

[Article Title: Interprofessional Collaboration Between a Clinical Pharmacist and Specialty Physicians to Treat Hepatitis C in an Interdisciplinary Medical Practice Setting/ Jennifer T. Fix, Steven Hauf, Michael Herrera, Randy Martin, Mason Sweeden and Karl Meyer, p. 335–342]

Abstract:

Objective: Describes the activities of a clinical pharmacist in a gastroenterology (GI) clinic providing services to hepatitis C virus (HCV) patients, with a focus on practice management activities and tools.

Practice Description: Located inside a GI specialty clinic in Fort Worth, Texas, the pharmacist provides comprehensive medication management under a collaborative practice agreement (CPA). Once referred by the GI physician, the pharmacist has face-to-face patient visits, develops the care plan, orders medications, and follows patients through sustained virologic response and the development of a hepatocellular carcinoma surveillance plan.

Practice Innovation: The role of pharmacists in the management of HCV is important to understand. This article details a pharmacist-led clinic in an open GI medical practice.

Evaluation: A retrospective chart review study was conducted to assess outcomes related to the integration of the clinical pharmacist.

Methods: Completed by the study team, this study included manual chart reviews of patients with the ambulatory care pharmacist-driven HCV practice to pull data and information that were then tabulated using Qualtrics.

Results: A total of 95 charts were surveyed, 78 records were created, and 49 patients were started on direct-acting antiviral (DAA) treatment by the pharmacist. Patients required multiple pharmacist communication actions. The minimum duration of the pharmacist service was 6 months and could extend more than 9 months depending on the time it took to get the patient started on medication. Pharmacist integration into the practice resulted in improved intake for the GI clinic, improved interprofessional interaction, and increased utilization of newer treatment modalities for HCV which feature cure rates up to 99% with limited side effects.

Conclusion: Clinical pharmacists are well positioned to help navigate patients through the complexities of the medication use system, medication access, drug interactions and adverse effects, promote medication adherence, and allow patients to start and complete therapy.

https://doi.org/10.1177/87551225221125428

[Article Title: Tricyclic Antidepressant Overdose Manikin Simulation in Student Pharmacists/ Alex M. Ebied, Jeremiah Jessee and Shaina Schwartz, p. 343–348]

Abstract:

Background: Pharmacists must be knowledgeable of medication use within the scope of both typical dosing and atypical dosing. In the United States, antidepressants are the fourth most common substance in overdose situations and are ranked first for serious exposures per year.

Objective: The purpose of this study is to design, implement, and assess the efficacy of an antidepressant overdose simulation using a high-fidelity manikin.

Methods: This was a single-center, prospective, observational, cross-sectional study of third-year student pharmacists in spring 2021. This study was determined to be exempt by the institutional review board. Students who did not participate in the manikin simulation or complete both the pre- and postsimulation surveys were excluded. Student pharmacists were expected to identify the type of overdose, identify probable offending agent, and evaluate the hemodynamic status. Primary objectives compared student pharmacist knowledge, confidence in recognizing overdose, and confidence in managing overdose pre- and post-antidepressant overdose manikin simulation.

Results: Twenty-three students completed both surveys and participated in the simulation. The knowledge total score was 2.1 ± 1.3 in the presimulation and 2.9 ± 0.9 in the postsimulation (P < 0.001). The recognition confidence was 2.0 ± 1.3 in the presimulation and 3.7 ± 0.7 in the postsimulation (P < 0.001). The management confidence was 1.8 ± 1.0 in the presimulation and 3.5 ± 0.5 in the postsimulation (P < 0.001). Limitations in this study were small sample size, lack of rubric, and a case prompt.

Conclusion: The outcomes were statistically significant postsimulation. Manikin simulations may have a larger impact on a pharmacy curriculum.

https://doi.org/10.1177/87551225221126613

[Article Title: Drug Interactions Associated With Therapies for Pulmonary Arterial Hypertension/ Shraddha Narechania and Mark A. Malesker, p. 349–359]

Abstract:

Objective: To evaluate the potential for drug interactions with therapies for pulmonary arterial hypertension (PAH). Treatments include calcium channel blockers, phosphodiesterase type 5 inhibitors, endothelin receptor antagonists, guanylate cyclase stimulators, prostacyclin analogues, and prostacyclin receptor agonists.

Data Sources: A systemic literature search (January 1980-December 2021) was performed using PubMed and EBSCO to locate relevant articles. The mesh terms used included each specific medication available as well as “drug interactions.” DAILYMED was used for product-specific drug interactions.

Study Selection and Data Extraction: The search was conducted to identify drug interactions with PAH treatments. The search was limited to those articles studying human applications with PAH treatments and publications using the English language. Case reports, clinical trials, review articles, treatment guidelines, and package labeling were selected for inclusion.

Data Synthesis: Primary literature and package labeling indicate that PAH treatments are subject to pharmacokinetic and pharmacodynamic interactions. The management of PAH is rapidly evolving. As more and more evidence becomes available for the use of combination therapy in PAH, the increasing use of combination therapy increases the risk of drug-drug interactions. Pulmonary arterial hypertension is also associated with other comorbidities that require concomitant pharmacotherapy.

Conclusion: The available literature indicates that PAH therapies are associated with clinically significant drug interactions and the potential for subsequent adverse reactions. Clinicians in all practice settings should be mindful that increased awareness of drug interactions with PAH therapy will ensure optimal management and patient safety.

https://doi.org/10.1177/87551225221114001

[Article Title: Complications of Corticosteroid Therapy: A Comprehensive Literature Review/ Elliott J. Koshi, Kurtis Young, Joshua C. Mostales and Lawrence P. Burgess, p. 360–367]

Abstract:

Relevance to Patient Care and Clinical Practice: Corticosteroids are among the most prescribed medications, particularly during the COVID-19 era. The literature has clearly highlighted the dangers of prolonged, high-dose corticosteroid use, which is important for clinicians to consider before treating patients in their clinical practices.

Objective: The objective of this article is to review the literature on complications of corticosteroid use, review corticosteroid pharmacokinetics, and provide an updated reference on risks associated with corticosteroid therapy, especially at higher doses.

Data Sources: A conventional literature search of PubMed was conducted without restrictions on publication date. Search terms included “corticosteroids,” “avascular necrosis,” “gastrointestinal bleeding,” and “complications.”

Study Selection and Data Extraction: Pertinent systematic review/meta-analyses and randomized controlled trials were reviewed for study inclusion.

Data Synthesis: Corticosteroids were associated with complications including avascular necrosis, gastrointestinal bleeding, myocardial infarction, heart failure, cerebrovascular events, diabetes mellitus, psychiatric syndromes, ophthalmic complications, tuberculosis reactivation, and bacterial sepsis. Increased daily and cumulative doses were associated with increased excess risk of complications. Cumulative doses greater than 430 mg prednisone equivalent were shown to increase the excess risk of avascular necrosis, with progressively higher rates with higher doses. Risk of gastrointestinal bleeding was significantly increased with corticosteroid usage in the in-patient but not out-patient setting.

Conclusion: Since corticosteroids have been associated with the aforementioned severe complications and frequent medicolegal malpractice claims, counseling and informed consent should be performed when prescribing moderate-high dosages of corticosteroids. Further research is needed to characterize the long-term effects of corticosteroid usage in COVID-19 patients.

https://doi.org/10.1177/87551225221116266

[Article Title: Setmelanotide: A Novel Targeted Treatment for Monogenic Obesity/ Haley Pressley, Cyrille K. Cornelio and Erin N. Adams, p. 368–373]

Abstract:

Objective: To review clinical data regarding the newly approved drug setmelanotide, an injectable melanocortin 4 receptor (MC4R) agonist, for chronic weight management in adults and children aged 6 years and older with monogenic obesity.

Data Sources: A literature review was performed by searching MEDLINE, SCOPUS, and EMBASE for all relevant English-language articles published between January 1, 1996, and November 30, 2021, using search terms obesity, setmelanotide, Imcivree, and MC4R agonist.

Study Selection/Data Extraction: This review included two phase 2, two phase 3, and one ongoing clinical trial evaluating the efficacy and/or safety of setmelanotide.

Data Synthesis: Setmelanotide demonstrates statistically significant weight loss with at least a 10% decrease in body weight after 1 year and decreased appetite in phase 2 and phase 3 clinical trials. The most common adverse effects included injection site reaction (96%), skin hyperpigmentation (78%), nausea (56%), headache (41%), and diarrhea (37%).

Place in Therapy: Setmelanotide is the first and only Food and Drug Administration–approved medication for the treatment of proopiomelanocortin, proprotein convertase subtilisin/kexin type 1, and leptin receptor deficiency in patients with obesity. It may be used in children and adults who have received genetic testing and exhibited extreme obesity before age five. Setmelanotide is a daily subcutaneous injection and may be difficult to afford for patients.

Conclusion: Setmelanotide is an effective treatment in patients with obesity and indicated genetic disorders.

https://doi.org/10.1177/87551225221116010

[Article Title: Enhanced Anticoagulant Effect of Warfarin When Co-administered With Quercetin/ Ruchit Patel, Allison Stine and Kimberly Zitko, p. 374–375]

Abstract:

Case Report
A 79-year-old man on stable warfarin therapy for atrial fibrillation presented with an international normalized ratio (INR) of 7.5. The patient started quercetin supplementation several days prior to a routine INR monitoring appointment, taking 1 capsule daily. The supplement was made by Natural Factors and came in a dosage strength of 250 mg quercetin and 500 mg of Vitamin C. The patient previously had a stable INR between 2 and 3 for months, with an INR of 2.5 five days beforehand. The patient had no recent changes to contributing factors. The patient was taking stable amiodarone therapy for 4 months prior to this episode with no other critical INR values. No adverse bleeding events were reported by the patient. The patient had been taking 1 warfarin 7.5 mg tablet once daily with a weekly dose of 52.5 mg. After the INR of 7.5, the patient stopped taking the quercetin supplement indefinitely and restarted warfarin therapy after missing one day. Five days after the initial INR, the INR was found to be 2.5. The patient’s most recent labs were red blood cell (RBC) count of 4.48 103/mm3, hemoglobin (HGB) of 13.7 g/dL, aspartate aminotransferase (AST) of 26 IU/L, alanine aminotransferase (ALT) of 18 IU/L, and a calculated creatinine clearance (CrCl) of 91 mL/min.

Discussion
Quercetin is a flavonoid that occurs in foods such as onions, apples, berries, teas, and red wine.1 This dietary supplement is often used by patients for the treatment of cardiovascular conditions and cancer prevention due to its potential antioxidant and anti-inflammatory effects.1 Dietary quercetin glycosides are hydrolyzed in the intestine to aglycone which is further conjugated to glucuronides or sulfates that are then absorbed.1 Once absorbed, quercetin is highly protein bound. Its half-life, along with its metabolites, range from 6 to 28 hours.1 Quercetin is known to inhibit CYP2C9 activity.1 It is excreted in the urine as glucuronide derivatives and methylated metabolites.1 Flavonoids are known to be highly protein bound in plasma.2
Warfarin is a vitamin K antagonist used as an anticoagulant.2 It is primarily metabolized by CYP2C9 which is inhibited by quercetin.2 More than 98% of warfarin is protein-bound and only unbound warfarin is biologically active.3 The mechanism of the interaction is theorized to be warfarin being displaced from albumin by quercetin in the blood plasma and inhibition of CYP2C9.4 There is evidence to show the metabolites of quercetin bind to albumin with high affinity, leading to strong displacement of warfarin.4 This suggests that high doses of quercetin can lead to an increased INR and risk of bleeding.
Based on the multiple factors involved in INR levels and brief timeframe of the interaction, the calculated drug interaction probability scale score was 3, suggesting possible drug interaction between warfarin and quercetin, and the Naranjo adverse drug reaction probability scale score was 5, indicating a probable adverse drug event.5,6 The patient’s otherwise stable condition and critical INR after initiation of quercetin follows a temporal pattern suggesting that stopping the quercetin resolved the issue. Health care professionals should be aware of this possible interaction when managing a patient’s warfarin therapy.

https://doi.org/10.1177/87551225221125667

[Article Title: Pharmacists’ Perceptions About the Effect of Work Environment Factors on Patient Safety in Large-Chain Retail Pharmacies/ Sarah G. Francis, p. 376–378]

Abstract: This commentary evaluates large-chain retail pharmacists’ perceptions on their work environment factors’ effects on patient safety from the July 2020 survey conducted by the Ohio Board of Pharmacy. Respondents rated 7 questions using a 5-point Likert scale to rate how they perceive work environment factors in large-chain retail pharmacies influence patient safety. Weighted average, weighted sums, and weighted total scores were calculated to determine if pharmacists’ perceptions were positive or negative. Low scores indicated pharmacists’ negative perceptions. Work factors in large-chain retail pharmacies need to change to improve pharmacists’ perception about work environment factors on patient safety.

https://doi.org/10.1177/87551225221116000