Safety and Efficacy of Sodium-Glucose Cotransporter-2 Inhibitors in Solid Organ Transplant Recipients.

Background: Sodium-glucose cotransporter-2 inhibitors (SGLT2i) may be effective in reducing body weight and hemoglobin A1c (HbA1c) post-kidney transplantation. Limited literature exists on use of these agents outside of kidney transplant. The purpose of this program evaluation was to evaluate the safety and efficacy of SGLT2i in kidney, liver, and lung transplant recipients. Methods: This was a retrospective program evaluation of adult kidney, liver, and lung transplant recipients between August 31, 2016 and July 31, 2021. Patients initiated on SGLT2i for diabetes for a minimum of 90 days with at least 1 follow-up appointment were screened for inclusion. Outcomes were compared between SGLT2i initiation to nadir values 3-12-months post-initiation. Outcomes included change in hemoglobin A1c, fasting blood glucose, actual body weight, and body mass index. Safety outcomes included adverse effects, cardiovascular events, death-censored graft loss, and all-cause mortality. Results: Forty-nine patients met inclusion criteria, (26 liver, 18 kidney, 4 lung, and 1 simultaneous liver-kidney recipient). The median time from transplant to SGLT2i initiation was 1216 days (IQR 524-2256). Glycemic and weight loss outcomes showed a statistically significant benefit from SGLT2i use. Total safety outcome incidence was minimal at 12 months. No patient experienced myocardial infarctions, graft loss, or mortality at 3-12 months. One incidence of urinary tract infection and stroke occurred each. The most common adverse effects included hypotension and hypoglycemia. Conclusion: This program evaluation demonstrated that SGLT2i can be used safely in solid organ transplant recipients. These agents can provide an additional non-insulin agent for post-transplant diabetes mellitus management in solid organ transplant.

Abuse and Misuse of Pregabalin and Gabapentin: A Systematic Review Update.

BACKGROUND: A 2017 systematic review (SR) identified 59 studies examining gabapentinoid (pregabalin and gabapentin) misuse/abuse. Evidence of gabapentinoid misuse/abuse has since grown substantially. OBJECTIVE: Update previous SR and describe new insights regarding gabapentinoid abuse. METHODS: A SR of PubMed was conducted to identify studies published from 7/29/2016-8/31/2020. Four searches were performed using the following terms: "gabapentin [MeSH] OR pregabalin [MeSH] OR gabapentinoid" AND one of the following substance misuse/abuse-related terms: "substance-related disorders [MeSH]", "overdose", "abuse", or "misuse". Clinicaltrials.gov and the Cochrane Library database were searched to identify ongoing studies or similar SRs. Reference lists of included studies were reviewed to identify additional literature. All studies with novel data related to pregabalin and/or gabapentin abuse, misuse, or overdose conducted during the study period were included. Articles not written in English, review articles, and animal studies were excluded. RESULTS: Fifty-five studies were included (29 [52.7%] from North America, 17 [30.9%] Europe, 6 [10.9%] Asia, and 3 [5.5%] Australia). Forty-six observational studies and 10 case reports/series were included (one manuscript included both). Twenty (36.4%) studied gabapentin only, 18 (32.7%) pregabalin only, and 17 (30.9%) both pregabalin/gabapentin. These studies corroborate findings from the previous SR that gabapentinoids are increasingly abused or misused to self-medicate, that gabapentinoids can produce desirable effects alone but are often used concomitantly with other drugs, and that opioid use disorder is the greatest risk factor for gabapentinoid abuse. While the original SR identified the largest studies having been published in Europe, this review identified several more generalisable US studies that have subsequently been conducted. The most concerning finding was increased evidence of associated patient harm, including increased hospital utilisation and opioid-related overdose mortality risk. CONCLUSION: Evidence suggests that gabapentinoid misuse/abuse represents a growing trend that is causing significant patient harm. Prescribers should exercise appropriate caution with use in high-risk populations and monitor for signs of misuse or abuse.

Pharmacist counseling when dispensing naloxone by standing order: A secret shopper study of 4 chain pharmacies.

BACKGROUND: Texas has passed legislation to increase access to naloxone, the opioid overdose antidote, allowing pharmacists to dispense by standing order without an outside prescription. Given this added responsibility, there is a need to assess real-world counseling provided by pharmacists when dispensing naloxone. OBJECTIVES: Assess naloxone accessibility and counseling provided by community pharmacists when dispensing naloxone by standing order. METHODS: A total of 11 student pharmacists (mean age 25 years; 63.6% female; primarily Hispanic [36.4%], Asian [27.3%], and white [27.3%]) audited community pharmacies by presenting to purchase naloxone. Variables included naloxone availability and price, counseling duration, and whether 13 predetermined counseling points were provided unprompted. Shoppers were prepared with a background story if asked so that each answered questions consistently. All shoppers participated in two 1-hour training sessions, including verification of their ability to accurately assess naloxone counseling. Pharmacies in Bexar County, TX were selected randomly from 4 pharmacy chains, each of which have implemented statewide standing orders within their chain. Descriptive statistics were calculated. A Fisher exact test and linear mixed-effects regression model were used to assess variation across chains in whether naloxone was dispensed and the mean total number of counseling points provided, respectively. RESULTS: The shoppers audited 45 pharmacies. Naloxone was dispensed in 31 of 45 (68.9%) encounters (mean cost: $129.59). The mean counseling duration was 89 seconds. The most common counseling points included: administration technique (24 of 31), readministration of second dose (22 of 31), and calling 9-1-1 (20 of 31). All other points were included in less than one-third of pharmacists' counseling. Across the 4 chains, there was significant variation in naloxone dispensing and the number of counseling points provided. CONCLUSION: Secret shoppers were unable to access naloxone from nearly one-third of pharmacies. Counseling often excluded concepts pertinent to patient safety and effectiveness, suggesting opportunities remain to promote consistent, high-quality naloxone counseling in community pharmacies.