Establishment of a pharmacist-led service for patients at high risk for opioid overdose.

PURPOSE: A program at a family medicine clinic to provide naloxone prescriptions in conjunction with education on naloxone use and opioid hazards to patients at risk for opioid overdose is described. SUMMARY: Consistent with a 2016 Centers for Disease Control and Prevention (CDC) guideline on opioid prescribing for chronic pain, a family medicine clinic implemented updated controlled substance agreements and medical record templates for documentation of pain management visits and established a pharmacist-led naloxone clinic. Chart reviews were performed to identify patients eligible for naloxone, as defined by the CDC guideline. A standard visit template was constructed to guide patient education regarding overdose risks and naloxone use. The teach-back method was used to ensure patient understanding, and patients were encouraged to bring a friend or family member to clinic visits. To address medication access barriers, community resources for patient referral for assistance were identified. Barriers to attendance at pharmacist-conducted visits necessitated changes in clinic workflow to incorporate education into prescheduled physician visits and education of some patients via telephone. During the first 6 months of clinic operations, 49 patients were identified as being at risk for opioid overdose; pharmacists educated 84% of those patients and subsequently confirmed that 69% had filled a naloxone prescription. CONCLUSION: Naloxone prescribing and provision of education on naloxone use to at-risk patients in a family medicine clinic can help ensure access to life-saving medication and reinforce CDC recommendations on safe prescribing of opioids.

Incorporation of lean methodology into pharmacy residency programs.

PURPOSE: The implementation of lean methodology into pharmacy residency programs at a community teaching hospital is described. SUMMARY: New Hanover Regional Medical Center, a community teaching hospital in southeastern North Carolina, fully adopted a lean culture in 2010. Given the success of lean strategies organizationally, this methodology was used to assist with the evaluation and development of its pharmacy residency programs in 2014. Lean tools and activities have also been incorporated into residency requirements and rotation learning activities. The majority of lean events correspond to the required competency areas evaluating leadership and management, teaching, and education. These events have included participation in and facilitation of various lean problem-solving and communication tools. The application of the 4 rules of lean has resulted in enhanced management of the programs and provides a set of tools by which continual quality improvement can be ensured. Regular communication and direct involvement of all invested parties have been critical in developing and sustaining new improvements. In addition to program enhancements, lean methodology offers novel methods by which residents may be incorporated into leadership activities. CONCLUSION: The incorporation of lean methodology into pharmacy residency programs has translated into a variety of realized and potential benefits for the programs, the preceptors and residents, and the health system. Specific areas of growth have included quality-improvement processes, the expansion of leadership opportunities for residents, and improved communication among program directors, preceptors, and residents.

Combination exenatide-sitagliptin therapy used with glipizide in a patient with type 2 diabetes mellitus.

PURPOSE: The case of a patient with type 2 diabetes mellitus who received combination exenatide-sitagliptin with glipizide is reported. SUMMARY: A 55-year-old, 204-lb Caucasian woman arrived at a clinic with polydipsia. Her blood glucose concentration was 450 mg/dL and her glycosylated hemoglobin (HbA(1c)) value was 13.4%. She was diagnosed with type 2 diabetes mellitus and started on metformin hydrochloride 500 mg orally twice daily. Metformin was later discontinued due to elevated liver function test values. Sitagliptin 100 mg daily was substituted, and glipizide was later added and its dosage adjusted over the next several months. After six months, her HbA(1c) value had decreased to 9.3% and she had gained 14 lb. Exenatide was then added to her regimen, and the dosage was adjusted to 10 µg subcutaneously twice daily. Two months after the initiation of sitagliptin, glipizide, and exenatide, the patient had lost 10 lb, reported significant improvements in self-monitored blood glucose readings, and required a reduction in glipizide dosage despite no reported therapeutic lifestyle changes. Seven months after the initiation of exenatide, sitagliptin, and glipizide, her HbA(1c) value was 7.4%. Triple therapy resulted in a total HbA(1c) value reduction of 1.9%, a weight loss of 11 lb, and normalized liver function test values. The patient's high blood pressure was treated with losartan and remained at goal throughout the duration of this report. CONCLUSION: In a patient with type 2 diabetes mellitus, the addition of the incretin mimetic exenatide and the dipeptidyl peptidase-4 inhibitor sitagliptin to glipizide therapy appeared effective and safe.