Developing an interprofessional team to support patients prescribed long-term high-dose opioid therapy.

Despite decreases in US opioid prescribing rates, daily morphine milligram equivalents (MME) prescribed per person remains three times higher than in 1999. An interprofessional team (IPT) was developed to support pain management for patients prescribed long-term high-dose opioids (HDO) in a Federally Qualified Health Center. The IPT utilized a clinical pharmacist, addiction nurse, medical director, and another physician or nurse practitioner to manage adults prescribed long-term HDO, defined as exceeding 50 daily MME. Visits focused on patient education including risks associated with long-term HDO use and effective pain management. The IPT engaged in supportive, individualized care planning for safer, evidence-based pain management, which included, but was not limited to opioid tapers, adjuvant non-opioid pain medications (NOPM), non-pharmacological therapy (NPT), and naloxone co-prescribing. The IPT saw 90% (n = 19) of eligible patients. Excluding outliers, the cohort demonstrated an average 18% ± 24.9 decrease in daily MME. The most common NOPM were acetaminophen, NSAIDs, and pregabalin, and the most common NPT were physical, aquatic, and behavioral therapy. Shared decision-making, collaborative teamwork, and simple patient-centered goals are key to moving patients toward safer, evidence-based therapy.

Real-world impact on monthly glucose-lowering medication cost, HbA1c, weight, and polytherapy after initiating a GLP-1 receptor agonist.

OBJECTIVE: Glucagon-like peptide-1 (GLP-1) receptor agonists are preferred injectable therapies for type 2 diabetes, but their high cost is an area of concern. This study evaluated monthly glucose-lowering medication cost and clinical impact after initiating a GLP-1 receptor agonist. DESIGN: A retrospective, pre-post cohort study evaluated monthly glucose-lowering medication cost, glycated hemoglobin (HbA1c), weight, and polytherapy impact (name, dose, and number of daily doses or injections) when a GLP-1 receptor agonist was initiated (baseline) and after 6-12 months (follow-up). The population was analyzed overall and as subgroups, based on baseline medication regimen and demographics. SETTING AND PARTICIPANTS: The study was performed at 8 ambulatory care sites (7 federally qualified health centers and a Program of All-Inclusive Care for the Elderly) in the greater Boston, MA, area. Patients were included in the analyses (n = 120) if they had a documented diagnosis of type 2 diabetes, were 18 years of age or older, had an HbA1c ≥ 7.5% measured within 3 months prior to the initiation of a GLP-1 receptor agonist, and an HbA1c measured 6 to 12 months following the initiation of a GLP-1 receptor agonist. OUTCOME MEASURES: Primary outomes were changes in glucose-lowering medication cost, HbA1c, and weight. Secondary outcome analyses included the impact to the glucose-lowering medication regimen in terms of dose, number of medications, and number of daily doses or injections. RESULTS: The study population was largely female, aged 55.8 ± 11.7 years, obese, 76% non-Caucasian, equally English and non-English speaking, had a high tablet and injection burden, and had an average baseline HbA1c of 10%. After the addition of a GLP-1 receptor agonist, monthly glucose-lowering medication cost increased $586.86 (overall), $741.69 (oral only baseline regimen), and $530.55 (insulin ± oral baseline regimen) (all P < 0.001). Mean decrease in HbA1c was 1.7% (18 mmol/mol) (P < 0.001) and was similar across all subgroups. Weight decreased overall (-1.8 kg, P < 0.001), and there was a significant shift toward taking fewer oral agents and insulin and fewer daily injections. No statistically significant differences in the primary outcomes were noted in terms of age, gender, English-speaking status, or race. CONCLUSION: Although a positive impact was observed in glycemic control, weight, and reduced polytherapy 6-12 months after initiating a GLP-1 receptor agonist, the increase in monthly glucose-lowering medication cost was significant and may serve as a barrier to treatment.

Evaluation of vitamin B12 monitoring in patients on metformin in urban ambulatory care settings.

BACKGROUND: Previous studies linked metformin use to vitamin B12 deficiency and demonstrated that the prevalence of vitamin B12 monitoring remains low. OBJECTIVE: This study aimed to assess the occurrence of monitoring vitamin B12 levels in a diverse population. METHODS: This was a retrospective chart review of adult patients with type 2 diabetes on metformin doses ≥ 1000 mg for ≥ 6 months at five Federally Qualified Health Centers (FQHC) and one Program of All-Inclusive Care for the Elderly (PACE). Charts were reviewed for occurrence of monitoring vitamin B12 levels in the past 5 years. Data collected included patient demographics, laboratory data, other potential vitamin B12 level lowering agents, active prescription for vitamin B12 supplementation, concomitant diabetes medications and metformin total daily dose. RESULTS: Of the 322 patients included, 25% had a vitamin B12 level measured in the previous five years. Among the patients with a vitamin B12 level, 87.7% were within the normal range (>350 pg/mL), 11.1% were low (200-300 pg/mL), and only one patient (1.2%) was deficient (<200 pg/mL). These patients were older (69.2 vs. 56.4, p<0.001); more likely to be white (56.8% vs. 37.8%, p=0.04); and more likely to use proton pump inhibitors (34.6% vs. 20.7%, p=0.02) and vitamin B12 supplementation (27.2% vs. 4.6%, p<0.001). Vitamin B12 monitoring differed between the FQHC (15.2%) and PACE (97.4%) sites (p<0.001). Each greater year of age was associated with a 5% increased odds of vitamin B12 monitoring (a OR: 1.05; 95% CI: 1.02-1.08). CONCLUSIONS: The majority of patients seen at the FQHC sites did not have vitamin B12 levels monitored, however, most of the patients who were monitored had normal vitamin B12 levels, which may warrant extending the monitoring time. This finding may also support monitoring patients who have additional risk factors for vitamin B12 deficiency such as concurrent medication use with other vitamin B12 lowering agents or clinical symptoms of deficiency such as peripheral neuropathy. Future studies are needed to determine appropriate frequency of monitoring.

Evaluation of vitamin B12 monitoring in patients on metformin in urban ambulatory care settings

Background: Previous studies linked metformin use to vitamin B12 deficiency and demonstrated that the prevalence of vitamin B12 monitoring remains low. Objective: This study aimed to assess the occurrence of monitoring vitamin B12 levels in a diverse population. Methods: This was a retrospective chart review of adult patients with type 2 diabetes on metformin doses ≥ 1000 mg for ≥ 6 months at five Federally Qualified Health Centers (FQHC) and one Program of All-Inclusive Care for the Elderly (PACE). Charts were reviewed for occurrence of monitoring vitamin B12 levels in the past 5 years. Data collected included patient demographics, laboratory data, other potential vitamin B12 level lowering agents, active prescription for vitamin B12 supplementation, concomitant diabetes medications and metformin total daily dose. Results: Of the 322 patients included, 25% had a vitamin B12 level measured in the previous five years. Among the patients with a vitamin B12 level, 87.7% were within the normal range (>350 pg/mL), 11.1% were low (200-300 pg/mL), and only one patient (1.2%) was deficient (<200 pg/mL). These patients were older (69.2 vs. 56.4, p<0.001); more likely to be white (56.8% vs. 37.8%, p=0.04); and more likely to use proton pump inhibitors (34.6% vs. 20.7%, p=0.02) and vitamin B12 supplementation (27.2% vs. 4.6%, p<0.001). Vitamin B12 monitoring differed between the FQHC (15.2%) and PACE (97.4%) sites (p<0.001). Each greater year of age was associated with a 5% increased odds of vitamin B12 monitoring (a OR: 1.05; 95% CI: 1.02-1.08). Conclusions: The majority of patients seen at the FQHC sites did not have vitamin B12 levels monitored, however, most of the patients who were monitored had normal vitamin B12 levels, which may warrant extending the monitoring time. This finding may also support monitoring patients who have additional risk factors for vitamin B12 deficiency such as concurrent medication use with other vitamin B12 lowering agents or clinical symptoms of deficiency such as peripheral neuropathy. Future studies are needed to determine appropriate frequency of monitoring

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Integration of the Pharmacists' Patient Care Process (PPCP) into a Comprehensive Disease Management Course Series.

Objective. To implement and assess the curricular integration of the Pharmacists' Patient Care Process (PPCP) in a course series for second- and third-year pharmacy students. Methods. The five-step PPCP was integrated within a four-semester pharmacotherapy course starting with the introductory course lectures. Beginning in the spring of 2015, the five steps of the PPCP were delivered to 129 P2 students, along with rollout of curricular integration within corresponding classroom and seminar activities and assessments. Integration focused on the development of course-specific lecture and seminar materials, a faculty guidance strategy and templates, and evaluation approaches for course assessments. Student comprehension and utilization of the PPCP were assessed via 61 unique assessments (12 examinations and 49 quizzes). Faculty incorporation and perception of the PPCP were evaluated via survey. Results. Overall, students demonstrated the most understanding on the lowest levels of the PPCP: 83.6% and 82.2% for the Collect and Implement components, respectively, compared to the higher-level components of Planning (78.0%) and Follow-up (76.0%). Faculty understanding, integration, and utilization of the PPCP in course materials were assessed approximately 6 months after implementation. Twenty-two faculty (96% of course instructors) participated in the survey. Eighteen (82%) have modified instructional materials to incorporate PPCP and among these, 89% agreed/strongly agreed that they possessed a clear understanding of the PPCP. Conclusion. Implementing a successful curricular change such as the integration of the PPCP across multiple courses requires a multi-faceted approach. The development of faculty templates and provision of support through various methods are necessary to ensure consistent and comprehensive integration across the curriculum. Additionally, evaluation of student performance and achievement of intended outcomes should be used to guide curricular assessments and continuous quality improvements throughout the process.

A review of advances in collaborative pharmacy practice to improve adherence to standards of care in diabetes management.

The prevalence of diabetes in the United States is increasing and so is the need to provide diabetes care. Given the time commitment and complexity of diabetes management, an interdisciplinary approach is recommended. Pharmacists are integral members of the diabetes care team because of their accessibility and expertise in medication management. Pharmacists are receiving specialized training and becoming more involved in direct patient care through collaborative practice opportunities such as medication therapy management and collaborative drug therapy management. These collaborative practice models increase patient access to care and allow pharmacists to optimize drug therapy and provide important education to promote diabetes self-management. Studies show pharmacists practicing in a variety of outpatient environments can reduce HbA1c, LDL and BP as well as improve adherence to recommended American Diabetes Association guidelines (yearly monofilament exams, dilated eye exams, microalbumin screening, etc). Pharmacists working as part of the health care team can ensure optimal diabetes management.

A peptide zipcode sufficient for anterograde transport within amyloid precursor protein.

Fast anterograde transport of membrane-bound organelles delivers molecules synthesized in the neuronal cell body outward to distant synapses. Identification of the molecular "zipcodes" on organelles that mediate attachment and activation of microtubule-based motors for this directed transport is a major area of inquiry. Here we identify a short peptide sequence (15 aa) from the cytoplasmic C terminus of amyloid precursor protein (APP-C) sufficient to mediate the anterograde transport of peptide-conjugated beads in the squid giant axon. APP-C beads travel at fast axonal transport rates (0.53 mum/s average velocity, 0.9 mum/s maximal velocity) whereas beads coupled to other peptides coinjected into the same axon remain stationary at the injection site. This transport appears physiologic, because it mimics behavior of endogenous squid organelles and of beads conjugated to C99, a polypeptide containing the full-length cytoplasmic domain of amyloid precursor protein (APP). Beads conjugated to APP lacking the APP-C domain are not transported. Coinjection of APP-C peptide reduces C99 bead motility by 75% and abolishes APP-C bead motility, suggesting that the soluble peptide competes with protein-conjugated beads for axoplasmic motor(s). The APP-C domain is conserved (13/15 aa) from squid to human, and peptides from either squid or human APP behave similarly. Thus, we have identified a conserved peptide zipcode sufficient to direct anterograde transport of exogenous cargo and suggest that one of APP's roles may be to recruit and activate axonal machinery for endogenous cargo transport.

The External RNA Controls Consortium: a progress report.

Standard controls and best practice guidelines advance acceptance of data from research, preclinical and clinical laboratories by providing a means for evaluating data quality. The External RNA Controls Consortium (ERCC) is developing commonly agreed-upon and tested controls for use in expression assays, a true industry-wide standard control.