What's Trending on Twitter Regarding the Most Recently Approved Oral Agent for HIV Pre-Exposure Prophylaxis (PrEP)?

Introduction: Pre-exposure prophylaxis (PrEP) is a key therapeutic strategy for HIV prevention. Descovy® is the most recently approved oral agent for PrEP. Despite availability, there continues to be suboptimal PrEP use among at-risk individuals. Social media platforms have a role in disseminating health information, to include education on PrEP. Material and methods: A content analysis was conducted of "tweets" posted on Twitter® during the initial year of Descovy's FDA approval for PrEP. The coding schema captured content related to the indication, appropriate use, costs, and safety profile of Descovy. Results: Most tweets provided information on target population, dosing strategy, and side effects of Descovy. Information on costs and appropriate use was frequently missing. Conclusion: Health educators and providers should be aware of gaps in social media messaging concerning PrEP and should educate patients to ensure they are well informed when considering PrEP.

Evaluation of Antidiabetic Injectable Technique: Is There an Association between Accuracy and Health Literacy or Duration of Diabetes?

INTRODUCTION: Effective diabetes pharmacotherapy often involves injectable medications, which if used inappropriately represents a type of unintentional medication nonadherence that leads to poor outcomes. OBJECTIVES: The primary objective of this study was to assess the percent of patients who accurately prepared, administered, stored, and disposed of their injectable diabetes medication. Secondary objectives included comparing the accuracy of injectable use among those with diabetes <5 years vs. ≥ 5 years duration and those with limited vs. proficient health literacy. METHODS: This was a prospective analysis conducted on a convenience sample of patients who received a pilot pharmacist-led, quality improvement service at an urban, ambulatory care clinic. The service components included health literacy screening, using the Rapid Assessment of Adult Literacy in Medicine - Short Form (REALM-SF) tool, evaluation of injectable technique by use of a standardized questionnaire, and provision of medication education. Duration of diabetes was determined by patient self-report. Chi-square and Fisher's exact tests were utilized to assess accuracy of injectable technique in two group comparisons: (1) patients with limited vs. proficient health literacy and (2) patients with diabetes <5 years vs. ≥5 years. RESULTS: Thirty-five patients were included in the analysis. Despite the majority (71.4%) of patients reporting prior education on injectable use, 54.3% reported at least one error in product use. Significant findings noted were that those with limited health literacy had higher rates of accurately using the skin-fold technique and appropriate angle for injection vs. those with proficient health literacy (p<0.05 for both comparisons). Likewise, more patients in the cohort of diabetes duration ≥5 years accurately rotated the injection site vs. those with a duration <5 years (p=0.001). CONCLUSION: Errors in injectable technique were common in this study and spanned across health literacy levels and duration of diabetes. Patients prescribed injectable diabetes medications should be routinely educated on proper technique for use.

Use of cannabidiol in anxiety and anxiety-related disorders.

OBJECTIVE: Cannabidiol (CBD) has a proposed novel role in the management of anxiety owing to its actions on the endocannabinoid system. The purpose of this systematic review was to evaluate the current evidence on the safety and efficacy of CBD in anxiety and anxiety-related disorders. DATA SOURCES: A literature search was conducted on PubMed, Google Scholar, and International Pharmaceutical Abstracts from database inception through June 2019. A bibliographic search of relevant articles was also conducted. STUDY SELECTION: Articles published from case reports, case series, or randomized controlled trials on human subjects were included in the review if they examined the safety and efficacy of CBD therapy in anxiety and anxiety-related disorders. DATA EXTRACTION: Two reviewers independently extracted the following data from the articles: year of publication; study design; patient characteristics (sex; type of anxiety disorder; use of concomitant anxiolytic therapy); dosing strategy and route of CBD administration; and safety and efficacy outcomes. RESULTS: Eight articles were included in the review: 6 small, randomized controlled trials; 1 case series; and 1 case report. These studies examined the role of CBD in the anxiety response of healthy volunteers; in generalized anxiety disorder; in social anxiety disorder; and in the anxiety component of posttraumatic stress syndrome. No articles that evaluated CBD in panic disorder, specific phobia, separation anxiety, and obsessive-compulsive disorder were identified. In the studies, CBD was administered orally as a capsule or as a sublingual spray and as either monotherapy or adjunctive therapy. Doses varied widely, with studies employing fixed CBD doses ranging from 6 mg to 400 mg per dose. Various anxiety assessment scales were used in the studies to assess efficacy, with CBD demonstrating improved clinical outcomes among the instruments. In general, CBD was well-tolerated and associated with minimal adverse effects, with the most commonly noted adverse effects being fatigue and sedation. CONCLUSION: CBD has a promising role as alternative therapy in the management of anxiety disorders. However, more studies with standardized approaches to dosing and clinical outcome measurements are needed to determine the appropriate dosing strategy for CBD and its place in therapy.

Noncarbapenems for the Treatment of Urinary Tract Infections Caused by Extended-Spectrum ß-Lactamase-Producing Bacteria.

OBJECTIVES: Urinary tract infections (UTIs) caused by extended-spectrum ß-lactamase (ESBL)-producing Enterobacteriaceae are resistant to many conventional therapies, including third-generation cephalosporins. Carbapenems are considered first-line agents for ESBL infections, but their use is associated with increased multidrug resistance and should be reserved when absolutely necessary. Because of the increased rates of UTIs caused by ESBL-producing organisms and incidence of carbapenem resistance, safe and effective alternatives to carbapenems are needed. This study was conducted to evaluate the outcomes associated with the treatment of ESBL UTIs with noncarbapenem antibiotics. METHODS: A retrospective cohort study of adults with ESBL UTIs was conducted at a community hospital. Patients were categorized as those receiving definitive carbapenem therapy and those receiving definitive noncarbapenem therapy. Calculated measurements included infection-related mortality, length of hospital stay, and duration of definitive antibiotic therapy. Microbiological failure was assessed as a secondary outcome. Data on the safety of antibiotic therapy were not collected. P < 0.05 was considered significant. RESULTS: Fifty patients met inclusion criteria for the study, divided evenly between the two cohorts. No statistical differences were observed for length of hospital stay (P = 0.601), duration of therapy (P = 0.398), or rate of microbiological failure between the groups (P = 0.115). CONCLUSIONS: Noncarbapenems did not demonstrate significant differences compared with carbapenems in the treatment of adults with ESBL UTIs. In certain patient populations, noncarbapenems that demonstrate in vitro activity may be appropriate for UTIs caused by ESBL-producing organisms.

Evaluation of Outcomes of a Pharmacist-Run, Outpatient Insulin Titration Telepharmacy Service.

PURPOSE: Diabetes can pose a significant disease burden for patients and is often challenging to manage in underserved patient populations with limited access to care. A pilot study was conducted to determine the impact of a pharmacist-run insulin titration service, provided via telephone, to patients of a local ambulatory care clinic with a large medically, underserved patient population. The pilot service was implemented in Spring 2018 at Cooper Green Mercy Health Services (CGMHS) and was provided by an affiliate clinical pharmacist who is also on faculty at Samford University's McWhorter School of Pharmacy. Patients who received care within the CGMHS diabetes clinic were eligible for referral to the service. The service was provided via a collaborative practice agreement. The purpose of this study was to evaluate and compare clinical outcomes of patients who received the telepharmacy service versus the standard of care. Standard of care was defined as patients whose insulin therapy was managed solely by the primary care provider or by a diabetes clinic provider, without clinical pharmacist involvement in the patient's care. METHODS: This manuscript presents the results of a retrospective chart review conducted at CGMHS of patients, ages 19 or older, with a documented diagnosis of type 1 or type 2 diabetes who received care during the timeframe of February 2018 through September 2018 - the initial months of the pilot telepharmacy service. RESULTS: Sixty-seven patients met criteria for inclusion in the analysis - 16 managed in the telepharmacy service, 28 in diabetes clinic, and 23 in primary care. Patients in the telepharmacy group achieved a mean A1c change of -1.14% compared with -0.88% in the diabetes clinic group and +0.21% in the primary care group (p=0.061). In the telepharmacy group, 43.75% of patients experienced at least a 1% reduction in A1c from baseline compared with 35.71% in the diabetes clinic group and 26.09% in primary care (p=0.51). CONCLUSION: Integration of the clinical pharmacy services for insulin titration positively affected patients' degree of glucose control. Although no statistically significant reductions in A1c were observed in this study, it should be noted that pharmacist intervention was associated with a modestly higher percent A1c reduction from baseline vs. the standard of care. The pharmacist-run service produced changes in clinical outcomes that numerically exceeded those experienced by patients receiving specialty care, in the diabetes clinic, and within primary care. As a result of this study, the pilot program has remained in effect and is in the initial stages of expansion of the consult service to eligible primary care patients.

Fracture Risk Following Discontinuation of Teriparatide: A Review of the Literature.

OBJECTIVE: To review and summarize studies on the changes in bone mineral density (BMD) and fracture risk following discontinuation of teriparatide therapy. DATA SOURCES: A search of PubMed (1966-May 2016) and International Pharmaceutical Abstracts (1970-May 2016) was conducted using the Medical Subject Headings terms teriparatide, osteoporosis, and withholding treatment. Free text searches included drug holiday, discontinuation, and drug discontinuation. STUDY SELECTION AND DATA EXTRACTION: These searches yielded 79 articles. There were 7 articles reviewed that addressed the effects of teriparatide discontinuation on markers of overall bone health and fracture risk. DATA SYNTHESIS: Teriparatide is a recombinant human parathyroid hormone that is indicated for a lifetime maximum of 24 months in the United States for the treatment of osteoporosis in men and women at high fracture risk. There is inconsistent evidence regarding retained skeletal integrity resulting from increased bone resorption. Study analyses have shown that female patients seem to have more reduction in BMD upon teriparatide discontinuation. Several studies evaluating teriparatide discontinuation were follow-up studies with small patient populations, limiting the generalizability and statistical rigor associated with assessing these outcomes. In addition, the majority of patients were receiving bisphosphonate therapy, and the true effect of discontinuing teriparatide remains unknown. CONCLUSION: Independent patient risk factors should be taken into consideration when weighing the risk-vs.-benefit of initiating and discontinuing teriparatide therapy. Additional randomized control trials should be conducted to determine long-term effects of discontinuing teriparatide in the presence and absence of other bone-strengthening agents.

Effects of Denosumab After Treatment Discontinuation : A Review of the Literature.

OBJECTIVE: To review and summarize studies on the effects of denosumab on bone mineral density following the discontinuation of therapy. DATA SOURCES: A search of PubMed (1966-July 2017) and International Pharmaceutical Abstracts (1970-July 2017) was conducted using the Medical Subject Headings (MeSH) terms denosumab, osteoporosis, and withholding treatment in combination with free term searches including the words drug holiday, discontinue, discontin*, and drug discontinuation. STUDY SELECTION AND DATA EXTRACTION: An initial review yielded 10 articles. Four articles that addressed the effects of denosumab discontinuation on markers of overall bone health, fracture risk, or bone histology were included in the final review. DATA SYNTHESIS: Denosumab is a monoclonal antibody indicated for the treatment of osteoporosis in men and postmenopausal women. Denosumab has proven beneficial effects on bone remodeling and bone mineral density, and these effects have been noted to be reversed upon treatment discontinuation because of the agent's lack of incorporation into bone matrix. After 12 to 24 months off denosumab therapy, BMD, BTMs levels, as well as histologic and histomorphometric analyses, were reflective of baseline values. The number of studies evaluating the residual skeletal effects of denosumab is limited, and the sample sizes in the articles reviewed were relatively small. CONCLUSION: An evaluation of studies showed that the discontinuation of denosumab results in loss of bone mineral density and a decline to near baseline values within 12 months of discontinuing therapy. Larger extension studies in a more diverse population need to be conducted to extrapolate the data to other patient groups.

Use of a Video Module to Improve Faculty Understanding of the Pharmacists' Patient Care Process.

OBJECTIVE: To evaluate change in faculty's knowledge and perceptions after an online video module on the Pharmacists' Patient Care Process (PPCP). INNOVATION: An educational video module on the PPCP was developed and disseminated to full-time faculty members at Samford University, McWhorter School of Pharmacy. Voluntary and anonymous pre- and post-test assessments were evaluated and analyzed. CRITICAL ANALYSIS: Thirty faculty completed the pre-assessment, and 31 completed the post-assessment (73% and 75% response rates, respectively). A significant improvement in faculty perceptions was indicated by an increase in agreement with the majority (80%) of questions on attitudes toward the PPCP on the post-test. Faculty's knowledge of the introduction and assessment of PPCP within the school's curriculum was significantly increased after viewing the video module. After viewing the module, more faculty were also able to correctly identify the majority of the PPCP components and their corresponding practice activities. NEXT STEPS: A short video module was effective at improving faculty knowledge and perceptions of the PPCP. Development of a similar faculty development module is feasible for implementation in other Schools of Pharmacy.

Pilot Study to Assess Outcomes of a Drug Allergy Clarification Service on a General Medicine Floor at a Local Community Hospital.

PURPOSE: Drug allergy documentation in the patient medical record varies in level of detail, and drug intolerances are often inappropriately documented as an allergy in the medical record. A pilot study was conducted to determine the impact of a pharmacy-led drug allergy clarification service. METHODS: The pilot quality improvement service was implemented in Fall 2016. General medicine patients were identified through daily census reporting and the electronic medical record (EMR) was reviewed within 72 hours of admission for documented drug allergies and/or intolerances. Patients were interviewed by a clinical pharmacist or a fourth year pharmacy student to determine a complete drug allergy and intolerance history. RESULTS: A total of 55 patients were interviewed and received the pilot service. A drug allergy/intolerance was documented in EMR for 54.5% (n=30) of patients interviewed. Of those 30 patients, 96.6% (n=29) were noted to have at least one discrepancy between EMR documentation and patient interview. The primary discrepancy noted was drug allergies or intolerances documented in the EMR without a description of the reaction. CONCLUSION: A pharmacy-led drug allergy clarification service was effective in identifying and clarifying EMR documentation of patients' drug allergies and intolerances. Patients with incorrect or incomplete allergy documentation may receive alternative therapy, which could increase costs and lead to unwanted adverse effects or less effective treatment. As a result of the pilot study, the program has remained in effect and is being expanded to other units within the institution.

Exercise-Induced Anaphylaxis in an Air Force Aviator Taking a HMG-CoA Reductase Inhibitor: A Case Report and Review of the Presentation, Diagnoses, and Treatment.

BACKGROUND: A 46-year-old healthy male Air Force pilot presented to the emergency department (ED) experiencing symptoms of exercise-induced anaphylaxis (EIAn), during a vigorous outdoor run. The patient recovered in the ED and was seen, subsequently, by a civilian allergist; eventually a diagnosis consistent with EIAn was made. EIAn is a rare but potentially life-threatening syndrome believed to involve IgE mediated release of histamine and other immunoactive compounds, during or after exercise. The diagnosis is determined by a strong clinical suspicion along with careful exclusion of other potential diagnoses. Interestingly, this particular patient was also found to have a possible correlation between the introduction of 3-hydroxy-3-methylglutaryl-coenzyme A, for hyperlipidemia, shortly before his first episode of EIAn, and remission of the condition since discontinuing the statin medication. METHODS: A detailed review of the clinical notes, ED presentation, and all subspecialty consultation notes were include in the compilation of this case report, in conjunction with a careful review of all current literature pertaining to drug exacerbated, exercise-induced EIAn. The review of literature was also conducted to review potential mechanisms of this particular hypersensitivity reaction, and to give a thorough discussion of the history and presentation of this disorder. RESULTS: The patient described in this case was successfully treated over a 2-year period, with exercise modifications and a daily second generation antihistamine. Nearly a year after his initial diagnoses, in an acute visit to the flight medicine clinic for muscle soreness and elevated creatine kinase isoenzymes, the patient's medication profile was reviewed and his statin medication was discontinued. The clinical notes revealed that the statin was started a few months before his first onset of EIAn, and following its discontinuation, the patient has been asymptomatic for over a year, exercising regularly, and completed a successful forward deployment to an austere desert environment. DISCUSSION: To our knowledge, this is the first reported case of possible statin exacerbated, EIAn. Data concerning the incidence of drug-induced hypersensitivity to statins are limited as is any discussion on prevalence of EIAn in adult populations. There have been, however, case reports documenting statin immunological effects on serum IgE levels, which may offer a potential mechanism of statin-exacerbated EIAn. However, the role of IgE antibodies in drug-induced anaphylactic reactions remains unclear. In this patient's case, there was no measure of statin-specific immune reactivity performed; however, the timing of statin initiation of monotherapy in relation to presentation of EIAn strongly supports the diagnosis of statin-exacerbated EIAn. Although the mechanisms involving statin-induced EIAn remain elusive, this case report illustrates the need for military providers to recognize this condition and cofactors that may contribute to its genesis. Moreover, this case also illustrates the need for increased research and surveillance of this condition in civilian and military populations.

Retained Skeletal Effects of Zoledronic Acid Following Discontinuation of Treatment: A Review of the Literature.

OBJECTIVE: To evaluate the effects on bone mineral density (BMD), bone turnover markers (BTMs), and fracture incidence following zoledronic acid (ZOL) discontinuation. DATA SOURCES: A search of PubMed (1966-May 2016) and International Pharmaceutical Abstracts (1970-May 2016) was conducted using the MeSH terms zoledronic acid, osteoporosis, and withholding treatment. Free text searches included drug holiday and drug discontinuation. STUDY SELECTION AND DATA EXTRACTION: An initial review yielded 87 articles. Six articles, which addressed the skeletal effects of ZOL after discontinuation of treatment, were included in the final review. DATA SYNTHESIS: ZOL is a widely prescribed bisphosphonate agent. Studies have shown that discontinuation of ZOL may have lasting skeletal benefits. However, there is inconsistent evidence regarding the duration of the residual skeletal effects of ZOL after treatment discontinuation, or the continued length of therapy required for the prolonged protective benefits on BMD and BTMs. Sample sizes have been small, and studies were not adequately powered to evaluate fracture incidence. CONCLUSION: A single ZOL infusion has been shown to decrease BTMs and improve BMD for at least 12 months after infusion. Patients may experience continued benefit beyond this period, but there is concern that this long-term effect may lead to severe bone-turnover suppression, increased bone fragility, and increased risk of fractures. Additional extension studies should be conducted to determine the long-term effects of discontinuing ZOL therapy on bone health as well as the length of preserved bone strength after last administration.

Pharmacists and HIV/AIDS prevention: review of the literature.

OBJECTIVES: To provide a summary of the available literature on pharmacists' participation in human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) prevention efforts, excluding needle exchange programs or highly active antiretroviral therapy (HAART) education, and to offer strategies based on the literature to expand pharmacists' roles in HIV/AIDS prevention efforts. DATA SOURCES: Data were collected from published reports indexed from database inception through December 2008 and identified through the Centers for Disease Control and Prevention's Prevention Research Synthesis database, Ovid, PubMed, Embase, and Cochrane Library. Search terms used were pharmacist or pharmacy and HIV and/or prevention or counseling or testing or screening. STUDY SELECTION: Only English language reports were included; studies that focused on needle/syringe exchange programs and HAART therapy education and adherence counseling were excluded. DATA SYNTHESIS: 13 reports were identified. The majority of articles were from international sources, and all focused on pharmacists and pharmacies as HIV/AIDS information resources. CONCLUSION: Findings from the available literature showed that most pharmacists served in treatment and prevention information resource roles but were interested in expanding their roles into other prevention efforts, including HIV testing with additional training. Pharmacists described in the reports expressed a need for specific training regarding HIV/AIDS knowledge and transmission.