Evaluation of Sodium-Glucose Transport Protein 2 (SGLT2) Inhibitor Prescribing Patterns in Heart Failure Patients at Hospital Discharge.

Background: Sodium-glucose cotransporter-2 inhibitors (SGLT2i) dapagliflozin and empagliflozin are indicated for heart failure with reduced ejection fraction (HFrEF) for cardiovascular death and heart failure hospitalization risk reduction. Due to the recent nature of these data, prescribing of SGLT2is may be suboptimal. Objective: This study sought to assess the prevalence of SGLT2i prescriptions at hospital discharge for HFrEF. Methods: A retrospective chart review was conducted on HFrEF patients discharged from April 1st to December 31st, 2021 from one academic medical center in the United States. The primary objective was to determine the percentage of eligible patients prescribed SGLT2i at discharge and the secondary objective was to characterize covariates impacting prescription. Results: Overall, 115 patients were included. The mean age was 72 ± 14.25 years. The majority were male (73.9%) and Caucasian (74.8%). At discharge, 15.7% of patients were prescribed an SGLT2i, although 94.8% were eligible. Baseline characteristics and concomitant medications did not differ significantly, although the mean number of discharge medications differed significantly between those prescribed an SGLT2i (15.78 ± 6.77) and those not (12.05 ± 5.28) (P = 0.023). Conclusions: SGLT2is are under-prescribed at discharge for HFrEF patients, despite many being eligible. Further studies should be done to elucidate factors that influence the under-prescription of SGLT2is.

Prescribing trends of SGLT2 inhibitors among HFrEF and HFpEF patients with and without T2DM, 2013-2021.

BACKGROUND: Sodium-glucose cotransporter-2 inhibitors (SGLT2i) are recommended for treatment of heart failure (HF), regardless of type 2 diabetes (T2DM) status. However, limited data exist on SGLT2i prescribing in HF patients without T2DM or across HF subtypes. METHODS: This was a serial, cross-sectional study of US MarketScan commercial and Medicare claims (2013-2021). Prevalence of SGLT2i was calculated by calendar year among HFrEF and HFpEF patients and stratified by T2DM status. RESULTS: Among 218,066 HFrEF patients [mean (SD): 54.9 (8.92) years; 66.4% male], the prevalence of SGLT2i use increased from 0.3 to 18.6%, while among 150,437 HFpEF patients [56.5 (7.77) years; 47.6% male], it rose from 0.5 to 9.9%. These increases were driven by the subgroup with comorbid T2DM. SGLT2i prevalence use ratios among patients with T2DM compared to those without decreased from > 100 in 2018 to 3.8 in 2021 among HFrEF patients, and from 83.1 in 2018 to 17.5 in 2021, coinciding with the publication of landmark trials and corresponding changes in clinical guidelines. CONCLUSIONS: SGLT2i use rose rapidly following changes in guidelines but remained low among those without T2DM. By the end of the study, approximately 1 in 3 HFrEF and 1 in 5 HFpEF patients with T2DM were using an SGLT2i, compared to only 1 in 11 HFrEF and 1 in 85 HFpEF patients without T2DM. Future work identifying barriers with the uptake of GDMT, including SGLT2i, among HF patients is needed.

Comparative Efficacy of Sodium Zirconium Cyclosilicate and Sodium Polystyrene Sulfonate for Acute Hyperkalemia: A Retrospective Chart Review.

Background: Sodium polystyrene sulfonate (SPS) is a nonselective sodium-potassium exchange resin commonly used along with intravenous (IV) insulin, albuterol, furosemide, and/or calcium for the treatment of acute hyperkalemia. Sodium zirconium cyclosilicate (SZC) is a newer non-absorbed exchange resin that preferentially increases fecal potassium excretion from the gastrointestinal tract. Limited data exists on the efficacy of SZC for the treatment of acute hyperkalemia. Objectives: To assess the achievement of normokalemia (serum potassium level [K+] 3.5-5.2 mmol/L) within 24 hours after administration of SZC or SPS in combination with insulin regular IV push. Methods: A multicenter, retrospective chart review (2020-2021) using electronic medical records at an academic health system. The study population included adult patients receiving one or more doses of SZC or SPS in combination with IV insulin for acute hyperkalemia (K+ >5.2 mmol/L). Patients receiving dialysis were excluded. Serum chemistries were assessed at baseline and an additional 2 values within 24 hours to determine normokalemia and hypokalemia at each follow-up. Results: Of 141 patients included, 51 received SZC and 90 received SPS. Normokalemia at the first follow-up was achieved in 51.0% of patients receiving SZC and 46.7% of patients receiving SPS (P = .622) and was sustained in 35.3%versus 44.4% (P = .289) of patients within 24 hours. Mean serum potassium differences from baseline to first follow-up were similar between SZC and SPS groups (0.9 mmol/L vs 1.0 mmol/L). Hypokalemia within 24 hours of administration occurred in 4 patients-1 in SZC, 3 in SPS. Conclusion: Both SZC and SPS yielded similar rates of normokalemia achievement with IV insulin for the treatment of acute hyperkalemia. Further prospective studies are needed to confirm these findings.

A Framework for Engaging Healthcare Professional Trainees as Continuing Education Activity Planners and Speakers.

Health professional education and post-graduate training programs, including residencies, fellowships, and other post-graduate training experiences, may encourage or require trainee participation in continuing education (CE) activity planning and development. Providers of CE should ensure appropriate mentorship and faculty guidance during development of the activity and provide direction on the expectations of adult learning principles (e.g. identification of an educational gap; development of measurable learning objectives; inclusion of independent, balanced, and evidenced-based content; use of active learning techniques; and incorporation of learning assessment methods). Nonetheless, there is no established best practice or approach for how CE providers should ensure trainees are prepared to serve as CE activity faculty. New practitioners provided with an opportunity to participate may be unsure of where to begin and may be hesitant to engage in this new activity. In this manuscript, authors delineate key principles to incorporate when introducing trainees to CE activity development and share outcomes associated with a comparison of trainee- vs. faculty-developed and delivered CE.

Cardiovascular outcomes with SGLT2 inhibitors versus DPP4 inhibitors and GLP-1 receptor agonists in patients with heart failure with reduced and preserved ejection fraction.

BACKGROUND: No study has compared the cardiovascular outcomes for sodium-glucose cotransporter-2 inhibitors (SGLT2i) head-to-head against other glucose-lowering therapies, including dipeptidyl peptidase 4 inhibitor (DDP4i) or glucagon-like peptide-1 receptor agonist (GLP-1RA)-which also have cardiovascular benefits-in patients with heart failure with reduced (HFrEF) or preserved (HFpEF) ejection fraction. METHODS: Medicare fee-for-service data (2013-2019) were used to create four pair-wise comparison cohorts of type 2 diabetes patients with: (1a) HFrEF initiating SGLT2i versus DPP4i; (1b) HFrEF initiating SGLT2i versus GLP-1RA; (2a) HFpEF initiating SGLT2i versus DPP4i; and (2b) HFpEF initiating SGLT2i versus GLP-1RA. The primary outcomes were (1) hospitalization for heart failure (HHF) and (2) myocardial infarction (MI) or stroke hospitalizations. Adjusted hazards ratios (HR) and 95% CIs were estimated using inverse probability of treatment weighting. RESULTS: Among HFrEF patients, initiation of SGLT2i versus DPP4i (cohort 1a; n = 13,882) was associated with a lower risk of HHF (adjusted Hazard Ratio [HR (95% confidence interval)], 0.67 (0.63, 0.72) and MI or stroke (HR: 0.86 [0.75, 0.99]), and initiation of SGLT2i versus GLP-1RA (cohort 1b; n = 6951) was associated with lower risk of HHF (HR: 0.86 [0.79, 0.93]), but not MI or stroke (HR: 1.02 [0.85, 1.22]). Among HFpEF patients, initiation of SGLT2i versus DPP4i (cohort 2a; n = 17,493) was associated with lower risk of HHF (HR: 0.65 [0.61, 0.69]) but not MI or stroke (HR: 0.90 [0.79, 1.02]), and initiation of SGLT2i versus GLP-1RA (cohort 2b; n = 9053) was associated with lower risk of HHF (0.89 [0.83, 0.96]), but not MI or stroke (HR: 0.97 [0.83, 1.14]). Results were robust across range of secondary outcomes (e.g., all-cause mortality) and sensitivity analyses. CONCLUSIONS: Bias from residual confounding cannot be ruled out. Use of SGLT2i was associated with reduced risk of HHF against DPP4i and GLP-1RA, reduced risk of MI or stroke against DPP4i within the HFrEF subgroup, and comparable risk of MI or stroke against GLP-1RA. Notably, the magnitude of cardiovascular benefit conferred by SGLT2i was similar among patients with HFrEF and HFpEF.

Paradoxical Excitation Following Intravenous Lorazepam Administration for Alcohol Withdrawal - A Case Presentation and Literature Review.

Benzodiazepines are commonly used medications which are clinically useful towards the treatment of alcohol withdrawal, seizures, anxiety disorders, among other indications. Benzodiazepine use is also known to cause the rare phenomenon of paradoxical excitation whose mechanism has many postulated theories. We report this rare presentation of paradoxical excitation with the use of lorazepam in a 50-year-old male being treated for alcohol withdrawal. We also review the underlying pathophysiology, pharmacology, and current literature as it relates to this excitation. An inability to recognize this adverse effect and to appropriately withhold the agent may adversely affect a patient's course of treatment in the inpatient setting.

The Role of Sodium-Glucose Cotransporter-2 Inhibition in Heart Failure with Preserved Ejection Fraction.

Sodium-glucose cotransporter-2 (SGLT2) inhibitors are a novel class of antidiabetic mediations found to also reduce cardiovascular morbidity and mortality and hospitalization for heart failure. Positive results from the EMPEROR-Preserved (empagliflozin) and PRESERVED-HF (dapagliflozin) studies led to recommendations for SGLT2 inhibitors in HFpEF within major international heart failure guidelines. However, studies of ipragliflozin and luseogliflozin, agents approved outside the United States (U.S.), reported different outcomes relative to pivotal trials and failed to realize benefits in the HFpEF population. Varying definitions of HFpEF and outcomes studied complicate the interpretation of study results. SGLT2 inhibitors may cause common adverse events (genital mycotic infections, volume depletion) in addition to rare but severe sequela, including euglycemic diabetic ketoacidosis, Fournier's gangrene, and lower limb amputation. While evidence of CV benefits grows, SGLT2 inhibitor prescribing has lagged, particularly among patients without diabetes. In the U.S., high cost and administrative hurdles may contribute to decreased patient and clinician uptake of this drug class. Future trial results and clinical experience with SGLT2 inhibitors may lead to expanded use and greater uptake among patients with heart failure.

Use of premedication with intravenous immune globulin in Kawasaki disease: A retrospective review.

BACKGROUND: Kawasaki disease (KD) is a significant febrile illness in children and is the leading cause of acquired pediatric heart disease in developed countries. Its recommended treatment is high-dose intravenous immune globulin (IVIG) plus aspirin. However, IVIG-related adverse events are seen frequently in this population. Premedication is commonly used to reduce this risk, but evidence supporting this practice is conflicting. Ultimately, practices vary among institutions and no standard guidelines regarding IVIG premedication currently exist. METHODS: Electronic medical records for pediatric patients presenting to an academic, tertiary care medical center diagnosed with KD and who received at least one dose of IVIG were reviewed for: patient demographics, treatment characteristics, premedication use, adverse events, and coronary abnormalities at discharge. Descriptive statistics were used to evaluate study findings. RESULTS: Sixty-six patients receiving a total of 81 distinct IVIG administrations were evaluated. Most patients (64/66, 97%) were premedicated prior to infusion with 26% of patients (17/66) experiencing an IVIG-related adverse event, totaling 25 documented adverse events. The most common events included chills and vomiting. Overall, the average duration of hospitalization was 4.37 days. Despite appropriate medication management, five patients (7.6%) developed coronary abnormalities. CONCLUSION: Practitioners demonstrated a widespread use of premedication for IVIG. However, 26% of patients still experienced an adverse event. While premedication was not shown to have an adverse impact on patient outcomes, it also did not demonstrate a notable reduction from a historic adverse event incidence.

Assessment of burnout among postgraduate pharmacy residents: A pilot study.

INTRODUCTION: Health professional burnout has become a topic of growing interest given increased focus on mental health and well-being. The Maslach Burnout Inventory-Human Services Survey (MBI-HSS) has been commonly utilized to quantify health professional burnout, but the literature does not report burnout among pharmacy residents. The objective of this study was to quantify burnout status of pharmacy residents and to correlate burnout to professional conduct and career outlook. METHODS: Pharmacy residents completed an electronic, anonymous survey at a teaching and learning certificate meeting date. Burnout status was measured by a high score on either the emotional exhaustion or depersonalization subscales of the MBI-HSS tool. RESULTS: Forty-three of 58 surveys were completed (response rate 74.1%). The burnout rate among residents was 74.4%. No significant differences were seen in baseline demographics, except burned out subjects were more likely to report a "single" relationship status. Activities such as using sick days when not ill, falling asleep at work, overlooking others' breaches of institutional guidelines, and failure to follow-up in a timely fashion were significantly correlated to burnout status with moderate correlation coefficients. CONCLUSIONS: The point prevalence of burnout among pharmacy residents is similar to that documented for practicing pharmacists and physicians. Expansion to a larger, more diverse sample size would provide additional power to differentiate independent risk factors for burnout and to better quantify associations to professional conduct among pharmacy residents.

Impact of Hydroxychloroquine on Mortality in Hospitalized Patients with COVID-19: Systematic Review and Meta-Analysis.

Coronavirus disease 2019 (COVID-19) caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) has caused significant health and economic havoc around the globe. One of the early agents targeted for repurposing to treat and prevent COVID-19 was hydroxychloroquine (HCQ). In this systematic review and meta-analysis, HCQ is evaluated for its potential role in decreasing mortality in hospitalized patients with COVID-19. We searched PubMed, Web of Science, and medRxiv databases using combinations of the terms "COVID-19", "SARS-CoV-2", "coronavirus", "hydroxychloroquine", and "mortality". Articles were selected for further review based on the content of their abstracts. Studies were excluded if they were of poor methodological quality, were not based in the inpatient setting, or did not have available data to assess the primary outcome of death between patients treated with HCQ versus standard of care. Once the final dataset was compiled, a meta-analysis using the random-effects model was performed. Our search identified 14 studies involving 24,780 patients of whom 12,707 patients were on HCQ alone or in combination with other adjuvant therapies. HCQ alone or in combination with other drugs did not significantly decrease mortality in hospitalized patients with COVID-19 (odds ratio [OR], 0.95; 95% CI, 0.72-1.26; p = 0.732; I2 = 91.05). Similar findings were observed in all subgroup analyses. HCQ did not significantly impact mortality in hospitalized patients with COVID-19. Additional well-designed studies are essential due to the heterogeneity in available studies.

Mechanism and Effect of Beta-Blockers on Pancreatic Adenocarcinoma: A Literature Review.

Pancreatic adenocarcinoma has a poor 5-year survival rate despite many advancements in pharmacotherapies. Studies have suggested the involvement of ß-adrenergic pathway in the progression of pancreatic adenocarcinoma. Animal experiments and retrospective trials have reported the use of beta-blockers as potential chemo-preventative agents. This review aims to discuss ß-adrenergic physiology as it relates to the progression of pancreatic adenocarcinoma and review outcomes on the use of beta-blockers for its treatment.

Comparison of Postdoctoral Pharmacy Training Programs: Drug Information Residencies and Medical Information Fellowships.

Pharmacy graduates interested in postdoctoral training opportunities in drug information or Medical Information have the option to pursue either a fellowship within the pharmaceutical industry or a clinical residency. Limited resources exist for pharmacy students to gain insight into the differences between drug information (DI) and medical information (MI) training programs. The purpose of this project is to identify available opportunities for postdoctoral training in DI or MI disciplines and to identify similarities and differences between them. DI residencies and MI fellowships were identified by examination of the American Society of Health-System Pharmacists (ASHP) and the American College of Clinical Pharmacy (ACCP) residency directories, the ASHP Personal Placement Service (PPS) index, and online keyword searching for nonindexed programs. The authors investigated individual programs via publicly available information to classify core responsibilities and skill sets developed; a total of 24 DI residency programs and 33 MI fellowships focusing or containing at least 1 component in medical information were evaluated. All ASHP-accredited DI residencies offered teaching, formulary management, adverse drug reaction and medication error reporting, drug utilization evaluation, and policy development as professional growth opportunities. The most commonly encountered development activities in MI fellowships were creating standard response documents, collaborating with cross functional teams, teaching or precepting, and reviewing promotional materials. Institutions and health care providers (HCPs) are the primary recipients of DI services whereas MI services respond to consumers, payors, HCPs, and external organizations. Employment prospects commonly overlap between the 2 training programs.

Transdermal estradiol for the management of refractory uremic bleeding.

PURPOSE: The efficacy and thrombogenicity of transdermal estradiol in the management of refractory uremic bleeding in adults are examined. SUMMARY: Platelet dysfunction from chronic kidney disease may induce uremic bleeding. This type of bleeding may involve the skin, oral and nasal mucosa, gingivae, respiratory system, and gastrointestinal or urinary tract. While the mainstay of treatment for uremic bleeding primarily involves dialysis and use of prohemostatic agents such as desmopressin and erythropoiesis-stimulating agents, certain patients may experience bleeding refractory to these interventions. In this clinical scenario, a weak conditional recommendation (grade 2C) supporting transdermal estradiol as a therapy of last resort exists. Limited data suggest that transdermal estradiol may reduce bleeding time and transfusion requirements in dialysis patients with recurrent episodes of hematochezia, gastrointestinal telangiectasia, and hematomas. The management of uremic bleeding will require long-term therapy, and case reports have documented the safe use of transdermal estradiol for up to 25 months. Oral conjugated estrogens increase the risk of deep vein thrombosis in women; however, the transdermal route of administration has been associated with a lower incidence of venous thromboembolism and stroke relative to oral estrogen and, in some studies, its associated risk of thrombosis is not significantly different when compared with placebo. CONCLUSION: Patients who are refractory to routine interventions for uremic bleeding may benefit from transdermal estrogen despite the limited data. Extended therapy with low-dose transdermal estrogen (≤50 µg daily) may provide a hemostatic benefit that outweighs thrombotic risk.

Differentiating predatory scholarship: best practices in scholarly publication.

OBJECTIVE: The intent of this article is to define predatory publishing, identify the risks and costs associated with publishing scholarship with these types of organizations and to provide recommendations for best practices how a potential author can protect themselves against predatory organizations. METHODS: A thorough review of the literature concerning predatory publishing was conducted and gleaned for best practices along with the authors' experiences. KEY FINDINGS: Pharmacy scholars and researchers worldwide recognize the virtues of the open access (OA) publication system, which is intended to freely disseminate research electronically, stimulate innovation and improve access to scholarship. Both subscription-based and OA publication systems, however, have potential areas of conflicts, including coordination of the peer-review process and the potential for the publisher to capitalize on selling the commodity in a capitalistic society. The intent of OA is welcomed; however, publishers are still in a business and profits need to be made. It is by the exploitation of the model that has given rise to a small but growing subset known as predatory publishers. CONCLUSIONS: Pharmacy researchers and clinicians alike need to be aware of predatory organizations, both publishers and meeting organizers, when seeking a venue to publish their own scholarly research. Additionally, this knowledge is critical when evaluating medical literature in providing direct patient care services to assure the best available evidence is utilized.

Angiotensin-converting enzyme inhibitor-induced angioedema: A review of the literature.

According to the National Health and Nutrition Examination Survey 2012, one third of antihypertensive prescriptions in the United States in the past decade were for angiotensin-converting enzyme inhibitors (ACEIs). An important and serious side effect of ACEIs is angioedema caused by a reduction in bradykinin degradation. In a national medical chart abstraction study conducted at the US Veterans Affairs Health Care System in 2008, 0.20% of ACEI initiators developed angioedema while on the medication. The angiotensin-converting enzyme is a part of the renin-angiotensin system that converts angiotensin I to angiotensin II. It is additionally responsible for the degradation of bradykinin, which is generated from high molecular weight kininogen by kallikrein. Via bradykinin 2 receptors, bradykinin affects vascular permeability and stimulates the release of substance P, which is a peptide that causes vasodilation and fluid extravasation into tissues. Inhibition of the angiotensin-converting enzyme and subsequent blockade of bradykinin degradation is thought to be a likely explanation for ACEI-induced angioedema. Studies have shown that blacks, women, and smokers are at an increased risk for ACEI-induced angioedema. A 2005 study identified black race, history of drug rash, age older than 65 years, and seasonal allergies as independent risk factors for angioedema related to enalapril. Angioedema may occur at any time during treatment with ACEIs and may continue after the medication is discontinued. The degree of ACEI-angiotensin receptor blocker angioedema cross-reactivity is difficult to determine from the literature. However, multiple studies have reported relatively low rates of native angioedema with angiotensin receptor blockers (approximately half that of ACEIs, or 0.1%) and a low incidence of cross-reactivity (<10%). Common treatments for angioedema, such as antihistamines and glucocorticoids, have not been shown to be effective in ACEI-induced angioedema. However, medications that have been used for acute treatment of hereditary angioedema and target the factors that cause ACEI-mediated angioedema are being explored.