Design, implementation, and evaluation of a pharmacist-led outpatient benzodiazepine-tapering clinic.

BACKGROUND: Benzodiazepines are commonly used among older adults, despite well-known risks. Clinical pharmacists can lead tapering efforts, leveraging their clinical expertise and relieving time-pressured primary care providers. OBJECTIVES: The objective of this study is to describe the design, implementation, and evaluation of an outpatient pharmacist-led benzodiazepine-tapering clinic. PRACTICE DESCRIPTION: The clinic is based within a community medical group associated with a large academic health system in Los Angeles, California. PRACTICE INNOVATION: The clinic is staffed by clinical pharmacists and supervised by a psychiatrist. The initial visit consists of patient education, design of patient-driven tapering schedule, and medical history review. Follow-up phone/video visits are used to monitor withdrawal symptoms and provide support. EVALUATION METHODS: We used chart review to assess tapering status among those enrolled in the tapering clinic versus those who did not enroll. We compared outcomes across the 2 groups using bivariate statistics. RESULTS: From March 2017 to May 2019, 176 patients were referred to the clinic; 17 were deemed ineligible. Of the 159 patients contacted, 62 patients enrolled in the clinic; 97 patients did not enroll. Among patients in the clinic, 13 (27%) of patients were tapered down, 29 (60%) completely tapered off, 6 (13%) were unable to taper, and 14 (23%) were in the process of tapering. In contrast, among patients who did not enroll, 3 (4%) of patients were tapered down, 15 (20%) completely tapered off, 57 (76%) were unable to taper, and 22 (22%) were in the process of tapering. Ninety percent of patients had at least some benzodiazepine tapering when enrolled in the clinic compared to 41% among not enrolled in the clinic (P<0.001). CONCLUSION: A pharmacist-led benzodiazepine-tapering clinic can be an effective way to engage patients motivated to taper down. Lessons learned include the importance of ensuring referring providers adequately counsel patients prior to referral.

National gender differences in the prescribing of opioid medications from 2006 to 2015.

OBJECTIVE: To identify gender differences in opioid prescribing from ambulatory care settings and identify factors associated with prescribing of opioids for men and women. DESIGN AND PARTICIPANTS: Retrospective analysis of data from The National Ambulatory Medical Care Survey from January 1, 2006 to December 31, 2015. Eligible patients were at least 18 years old on the date of the physician office visit. Data were collected on patient demographics and clinical factors. Data were analyzed using bivariate and multivariate logistic regression models to explore differences in opioid prescribing among men and women. Due to the large sample size, the significance level was set to p < 0.001. MAIN OUTCOME MEASURE: Opioid prescribing during an office visit. RESULTS: A total of 322 957 ambulatory care visits for adults were included in the analysis representing 7.8 billion weighted visits nationally. In 771 601 088 (9.8 percent) visits, an opioid was prescribed. Women received an opioid prescription at 9.4 percent of visits compared to 10.4 percent of visits for men. Gender differences for factors including age, region, payment method, and pain diagnosis were observed (p < 0.001). Women had a higher number of visits with an opioid (449 277 925 vs 322 323 163), but men had higher odds of being prescribed an opioid (OR: 1.214; CI: 1.214-1.214). CONCLUSION: Men are more likely to be prescribed an opioid as compared to women, but women are being prescribed more opioids overall. Gender differences should be further explored to develop gender-specific interventions to reduce opioid prescribing.

Drug interactions with antimalarial medications in older travelers: a clinical guide.

Increasingly older adults are traveling to international destinations with malaria as a present risk. Surveillance systems indicate that older adults are more likely to suffer severe complications from malaria. The role of health care providers in selecting an appropriate medication for chemoprophylaxis or treatment of malaria in adults becomes more difficult as older adults undergo physiologic changes that alter the pharmacokinetic and pharmacodynamic nature of medications potentially causing increased drug interactions, adverse events and altered drug action. A comprehensive literature search from 1970 to present, with a focus on the past 10 years, was conducted on drug interactions, pharmacokinetic and pharmacodynamic effects on antimalarials in adults. It was determined that due to pharmacodynamic and pharmacokinetic changes in older adults, especially renal and cardiovascular, special attention should be given to this population of travelers in order to minimize the likelihood of adverse events or altered drug efficacy. Antimalarial drug-disease interactions in older adults can occur more often due to QT prolongation, exacerbation of hypoglycemia, decreased renal elimination and decreased hepatic metabolism. Older antimalarials have well-documented drug-drug interactions. Tafenoquine, a new antimalarial, requires glucose-6-phosphate dehydrogenase screening like primaquine and monitoring of new potential drug interaction with MATE1 and OCT2 substrates. While drug-drug interactions in older travelers may occur more often as a result of polypharmacy, data did not indicate adverse reactions or decreased drug efficacy is greater compared with younger adults. Overall, with the exception of recently approved tafenoquine, much is known about antimalarial drug and disease interactions, but new drugs are always being approved, requiring travel health providers to understand the pharmacokinetics and pharmacodynamics of antimalarial drugs to predict the impact on safety and efficacy in travelers. This guide provides travel health providers with valuable insights on potential outcomes associated with drug interactions in adults and recommended monitoring or drug regimen modification.

A Review of Clinical Guidelines and Pharmacotherapeutic Management of Hypertension in Older Adults.

OBJECTIVE: To provide an up-to-date review of current hypertension (HTN) guidelines and discuss pharmacotherapeutic management of HTN in the older adult population.
DATA SOURCES: A PubMed search of articles published through June 2018 was performed using a combination of the following words: elderly, older adults, geriatric, and HTN.
STUDY SELECTION/DATA EXTRACTION: Relevant original research, review articles, and guidelines were assessed for the management of HTN in older adults. References from the above literature were also evaluated. Articles were selected for inclusion based on relevance to the topic, detailed methods, complete results, and after a thorough discussion among the authors.
DATA SYNTHESIS: HTN is a common chronic disease state in older adults. Until recently, most guidelines recommended a higher threshold for blood pressure targets in this population, compared with the general adult population. In 2017, two new guidelines for the management of HTN were published, which provided conflicting recommendations for blood pressure goals in the older population. This article reviews current U. S. HTN guidelines published in 2014 to 2017 that most commonly influence patient care, and it specifically addresses the blood pressure targets and pharmacotherapeutic management of HTN in older adults.
CONCLUSION: Management of HTN in older adults is important to avoid further complications and improve outcomes in this population. Blood pressure targets and HTN management should be individualized in older adults based on comorbid conditions, life expectancy, and risk for adverse drug events.

Management of Venous Thromboembolism in the Elderly: A Review of the Non-Vitamin K Oral Anticoagulants.

Objective To provide an up-to-date review of the available evidence regarding pharmacotherapeutic management of venous thromboembolic events in the geriatric population. Data Sources A PubMed search of articles published through August 2017 was performed using a combination of the following words: apixaban, betrixaban, dabigatran, edoxaban, enoxaparin, geriatric, heparin, idaricizumab, rivaroxaban, and venous thromboembolism. Study Selection/data Extraction Relevant original research, review articles, and guidelines were assessed for the management of elderly patients with venous thromboembolism (VTE). References from the above literature were also evaluated. Articles were selected for inclusion based on relevance to the topic, detailed methods, and complete results. Data Synthesis VTE, which includes deep vein thrombosis and pulmonary embolism, is common in the geriatric population. Elderly patients are at high risk for VTE, but management is complicated by comorbidities and a higher risk of bleeding. Until recently, warfarin has been the mainstay of therapy. Newer oral anticoagulants, which include apixaban, dabigatran, edoxaban, and rivaroxaban are now available, but there is limited information on their safety and efficacy in the geriatric population. This article reviews the current literature regarding outcomes and summarizes pharmacotherapeutic management of VTE in the elderly population. Conclusion Appropriate management of pharmacotherapy for VTE can help improve outcomes in elderly patients, and pharmacists can provide guidance and education regarding evidence-based therapy.