Buprenorphine Use for Analgesia in Palliative Care.

Buprenorphine is a semi-synthetic long-acting partial µ-opioid receptor (MOR) agonist that can be used for chronic pain as a sublingual tablet, transdermal patch (Butrans®), or a buccal film (Belbuca®). Buprenorphine's unique high receptor binding affinity and slow dissociation at the MOR allow for effective analgesia while offering less adverse effects compared to a full agonist opioid, in particular, less concern for respiratory depression and constipation. It is underused in chronic pain and palliative care due to misconceptions and stigma from its use in opioid use disorder (OUD). This case report discusses the unique pharmacology of buprenorphine, including its advantages, disadvantages, available formulations, drug-drug interactions, initiation and conversion strategies, and identifies ideal populations for use, especially within the palliative care patient population.

A Review of Olanzapine in the Treatment of Cancer Anorexia-Cachexia Syndrome.

BACKGROUND: Cancer anorexia-cachexia syndrome (CAS) is a multifactorial condition that is highly prevalent in advanced cancer patients and associated with significant reduction in functional performance, reduction in quality of life, and increased mortality. Currently, no medications are approved for this indication. Recently, the American Society of Clinical Oncology (ASCO) released a rapid recommendation suggesting that low-dose olanzapine once daily may be used to treat cancer cachexia. Many questions still exist on how to use olanzapine for this indication in clinical practice. The objective of this review is to identify existing knowledge on the use of olanzapine for CAS. METHODS: A comprehensive search was conducted to identify the primary literature that involved olanzapine for anorexia and cachexia in cancer patients between 2000 and 2023. RESULTS: Seven articles were identified and are discussed here, including two randomized double-blinded placebo-controlled studies, one randomized comparative study, two prospective open-label studies, one retrospective chart review, and one case report. CONCLUSIONS: Low dose olanzapine (2.5-5 mg once daily) may be useful in the treatment of CAS for increasing appetite, reducing nausea and vomiting, and promoting weight gain. Further large-scale multi-center randomized placebo-controlled studies will be needed to investigate the impact of olanzapine on weight change in CAS patients.

A Qualitative Analysis to Understand Perception about Medication-Related Problems among Older Minority Adults in a Historically Black Community.

Older adults taking multiple chronic medications experience an increased risk of adverse drug events and other medication-related problems (MRP). Most current literature on medication management involves researcher-driven intervention, yet few studies investigate patients' understanding of MRP in a diverse community setting. This report investigates patients' perception of MRP and patient-centered strategies among a cohort of the older adult group in a historically Black urban community. The study design is qualitative using structured open-ended questions in a multidisciplinary patient-centered focus group. Patients (age 65 years or older) taking seven or more medications were recruited. The group comprises patients, caregivers, pharmacists, health educators, a physician, and a nurse. Recordings of the group discussion are transcribed verbatim and analyzed using thematic content analysis and categorized by codes developed from the social-ecological model. The group reports patient-provider relationships, previous experience, fear of side effects played important roles in medication adherence. There is an unmet need for medication management education and tools to organize complex medication lists from multiple providers. This study provides important insights into MRP experienced by minority older adults and provided researchers with potential strategies for future interventions.

The Role of an Inpatient Hospice and Palliative Clinical Pharmacist in the Interdisciplinary Team.

Palliative care is a specialized health care service for individuals with serious illness at any stage and can be provided in any setting. Current national consensus developed by palliative care experts recommends the inclusion of pharmacists in an interdisciplinary team (IDT) to provide quality palliative care. However, national registry data report that less than 10% of inpatient palliative teams in the U.S. have a clinical pharmacist. Clinical pharmacists have an impactful role in palliative patients' quality of life by optimizing symptom management, deprescribing, and providing education to the palliative care team as well as patients and their families. In this report, we review the current literature on the role of a palliative pharmacist in an inpatient palliative care setting and compare and contrast this with our own clinical practice, providing case examples about the role of a palliative clinical pharmacist in an interdisciplinary inpatient palliative care setting. Future strategies are needed to increase post-graduate specialized pharmacy residency training in palliative care as well as education on palliative and hospice care in pharmacy schools to support the role of clinical pharmacists in palliative care.

Effect of Pharmacist Home Visits on Weight Control in Overweight Elderly Hypertensive African American Patients: Managing Your Blood Pressure (My Bp) Program.

OBJECTIVE: The objective was to investigate the effect of a home-based pharmacy intervention on body mass index (BMI) in a cohort of older hypertensive overweight African American (AA) patients. DESIGN: A secondary analysis of data collected in a community-based intervention study. SETTING: Community-based. PARTICIPANTS: AA patients, ≥ 65 years old, residing independently, with hypertension diagnosis and BMI ≥ 25. INTERVENTIONS: During a 6month period, patients received 1) two in-home pharmacist-led consultations on weight management, 2) bi-weekly telephone counseling, and 3) health education strategies. MAIN OUTCOME MEASURES: BMIs at baseline and 6 months; stages of behavioral change in diet and exercise based on the Transtheoretical Model. RESULTS: At baseline and 6-month follow-up, a total of 153 participants had BMI ≥ 25 and received a completed assessment of behavioral stages. Participants' mean age was 74.2 years. A reduction of BMI from 31.7 (obese) at baseline to 29.8 (overweight) at 6-months (p=0.0008) was observed. For every stage of improvement in diet, there was a reduction of 1.24 points in BMI (p=0.008). For every stage of progress in exercise, there was a reduction of 0.77 points in BMI (p=0.013). CONCLUSION: Pharmacists-led in-home consultations coupled with telephone follow-ups and health education strategies may improve lifestyle and lower BMIs in this cohort. Further studies are needed to investigate these strategies on weight management in geriatric patients with chronic illnesses.

Applying the Social-Ecological Approach to Evaluate Diabetes Medication Management in Older People.

Glucagonlike peptide-1 receptor agonist is a common antidiabetic medication class to lower HbA1c, weight, and cardiovascular risk. This case study describes the challenges a patient with uncontrolled diabetes faced after receiving a prescription for liraglutide because of multiple levels of influence, including individual, family, institutional, and policy level barriers. The case highlights the importance of utilizing a person-centered care approach by evaluating patient's preferences, visual and motor coordination, cognitive function, psychological stress, and medication cost before prescribing injectable products for elderly patients.

Building Community-Engaged Multidisciplinary Partnerships to Improve Medication Management in Elderly Patients With Multiple Chronic Conditions.

PURPOSE: Many studies in preventing adverse drug events have been researcher-driven, yet few have engaged patients in the development of a project. This project aims to engage minority elderly patients with multiple chronic conditions in the development of research questions and strategies to improve medication safety. METHODS: Elderly patients (≥65 years old) who were prescribed 7 or more chronic medications were recruited through a university-based aging resource network in a historically African American community in Houston, Texas. Patients and a caregiver participated in a multidisciplinary workgroup comprised of a physician, pharmacists, a nurse, health educators, and a social worker. Patients were engaged by utilizing the 4 patient-centered outcomes research engagement principles. The workgroup created a strategic plan, completed an environmental scan, identified research problems, and reviewed current evidence-based approaches in the literature. Workgroup findings were presented to a broader audience within a community town hall setting, and input was collected from a community-wide survey. RESULTS: From April 2018 to July 2018, 3 patients and 1 caregiver participated in 5 multidisciplinary workgroup meetings. A total of 74 seniors attended the town hall meeting, and 69 completed the surveys. The most common drug-related problems among survey participants were doubts about drug advertisements (79%) and drug interactions (70%). Most participants (88%) were more comfortable in receiving face-to-face counseling compared to an app or virtual visits. Findings aided in developing 3 grant proposals. CONCLUSIONS: This narrative provides a roadmap for conducting multidisciplinary, patient-centered participatory research to refine research strategies in minimizing drug-related problems.

Implementation of a medication adherence program in senior public housing facilities utilizing pharmacists and health educators.

BACKGROUND: Hypertension and diabetes disproportionately impact people of color when compared to majority populations. Medication adherence among seniors with chronic diseases has been suboptimal with the estimation that only half of those taking antihypertensives are adherent. Therefore, the purpose of The Managing Your Medications (MY Rx) program was to evaluate the effectiveness of evidence-based practices used to improve rates of medication adherence through information dissemination among diabetic and hypertensive African American, Asian American, and Hispanic residents housed in senior public housing facilities in the Greater Houston Area. The program comprised an 8-week intervention with individual and group components with small incentives provided throughout the program. Individual components included one home visit and telephone consultations conducted by pharmacists. Health educators provided two group education sessions on lifestyle modifications. RESULT: Qualitative analysis of focus group discussions revealed participant satisfaction with the MY Rx program and willingness to change after participation in the program. CONCLUSION: The Rx program showed the potential effectiveness of an innovative strategy in medication counseling using interdisciplinary pharmacists and health educators to promote health. It demonstrated the importance of using the patient-centered care framework in designing a community intervention program.

Managing Medication Adherence in Elderly Hypertensive Patients Through Pharmacist Home Visits.

OBJECTIVE: The purpose of the Managing Your Blood Pressure program was to reduce health disparities in blood pressure (BP) control by improving medication adherence in a cohort of geriatric African-Americans with hypertension (HTN). DESIGN: The program was implemented using a quasi-experimental pre- and postintervention study design that utilized a pharmacist home-based model and follow-up educational phone calls to impact BP over a six-month period. SETTING: Home visits occurred in participants' residences, and phone calls occurred at program headquarters at Texas Southern University (Houston, Texas). MAIN OUTCOME MEASURES: The primary outcome measure was BP control rate, and secondary outcome measures were knowledge of HTN, medication adherence, and use of a BP monitor. RESULTS: At six months, 306 of the 431 patients recruited completed all phases of the program (two in-home consultations and biweekly telephone consultations). At the end of the six-month intervention period, the reduction in mean systolic BP was statistically significant (baseline 140 mmHg vs. six months 137 mmHg; P < 0.049). No difference in mean diastolic BP pre- and postintervention was found. The percent of patients with controlled BP improved from 46.7% to 49.5%; P = 0.34. Medication adherence, self-monitoring of BP, and knowledge of HTN were significantly improved from baseline to postintervention. CONCLUSION: Pharmacist-led interventions in the home were effective in improving BP control and medication adherence. Further programs are needed to address uncontrolled HTN in this vulnerable population.

Biotransformation and pharmacokinetics of inositol hexanicotinate in rats.

Inositol hexanicotinate (IHN) is an ester of the anti-hyperlipidemic drug nicotinic acid (NA). This study assessed the hydrolysis rate of IHN in human and rat plasma, and pharmacokinetics of the drug using a rat animal model. IHN (10 or 50 µg/mL) was incubated in plasma at 37 °C for 72 h. Kinetic parameters were determined based on the disappearance of IHN and the appearance of NA. The mean IHN disappearance and NA appearance half-lives were 1.07 and 3.93 h in human plasma, and 0.152 and 2.68 h in rat plasma. Increasing the initial plasma concentration to 50 µg/mL increased the NA appearance half-life in human and rat plasma to 4.66 and 6.47 h, respectively. After single 50 or 100 mg/kg intravenous dose of IHN to Sprague-Dawley rats, the drug showed statistically significant dose-dependent alterations in systemic clearance, suggesting a non-linear saturable elimination of IHN. Dose-normalized mean plasma levels of NA increased by 30% with increasing IHN dose (p < 0.02). The mean metabolic ratio (i.e. NA/IHN AUC ratio) significantly increased with increasing IHN dose (p < 0.05). The results provide first indication of saturable elimination and rapid disappearance of IHN, while niacin was slowly formed.

Does the use of home blood pressure monitoring vary by race, education, and income?

OBJECTIVE: Home blood pressure (BP) monitors are commonly recommended for patients with hypertension, but little is known about their utilizations among different racial/ethnic groups. The objective of this study was to investigate if racial differences existed in the utilization of home BP monitoring devices. DESIGN: A voluntary and self-administered survey study. SETTING: Community pharmacies in the Greater Houston metropolitan areas, Texas, United States. PARTICIPANTS: Subjects were recruited from community pharmacies if they were aged > or = 18 years and received a prescription drug for hypertension. INTERVENTIONS: Each participant was given informed consent to complete a survey that consisted of questions about patient demographics and BP self-monitoring behavior. MAIN OUTCOME MEASURES: The primary measures were the use of home BP monitors and the patient's knowledge of BP monitoring. RESULTS: A total of 987 pharmacy customers were approached, of whom 834 patients agreed to participate (34.3% African Americans, 33.3% Whites, and 28.9% Hispanics). We found no association between race and BP monitor utilization. Patients with less education and lower income were associated with lesser use of BP monitors (P=.04 and P<.01 respectively). Patients with higher education and higher incomes were more knowledgeable about how to monitor BP at home. (P<.01). CONCLUSION: This study found that the utilization of BP monitors was not different among races. Patients with lower education level and less income were associated with less home BP monitor use. Further studies to investigate the adherence to home BP monitor use and intervention to overcome barriers to self-monitoring is needed.

Perceived value of a home-based medication therapy management program for the elderly.

OBJECTIVE: To provide a model for a home-based medication therapy management (MTM) program provided by a pharmacist and to determine the perceived value of the service by program participants. DESIGN: Cross-sectional study. SETTING: Houston (Harris County), Texas. PARTICIPANTS: Thirty MTM participants 60 years of age or older identified between June 2006 and June 2007 by the Harris County Area Agency on Aging as candidates in need of medication management services. INTERVENTION: Hand-delivered survey provided to participants following individual MTM and emergency-preparedness counseling by a pharmacist in their homes. MAIN OUTCOME MEASURES: Measures of participants' program satisfaction, opinion of knowledge level gained, and the impact participants' felt the program would have on their physician visits. RESULTS: Ninety-six percent of the participants in the MTM program felt knowledgeable or very knowledgeable about their medications after the pharmacist visit. Approximately 73% felt the home visit would reduce their visits to the doctor, 72% were very satisfied, and 22% somewhat satisfied with the program. All participants would strongly recommend the program to others. CONCLUSION: There is a lack of literature on home-based medication management programs performed by pharmacists. This report describes a unique program, which was perceived as positive and valuable by participants. This was demonstrated by the high rates received in the areas of satisfaction with the program and a willingness to recommend the program to others.

Effects of antihypertensive drug treatment on the risk of dementia and cognitive impairment.

Dementia is a common and serious health problem that affects 33 million persons globally. With the increase in life expectancy, the prevalence of dementia is expected to reach 81.1 million persons by 2040. Dementia impairs quality of life and is associated with profound disease burden, morbidity, and mortality in both patients and caregivers. Therefore, identifying measures to prevent dementia is a research priority. Midlife hypertension has increased the risk of dementia in large prospective cohort studies. Researchers have investigated the blood pressure-lowering effects of antihypertensive drugs on the incidence of dementia. Although prospective cohort studies have shown that use of antihypertensive drugs was associated with a reduced rate of cognitive impairment and dementia, these studies were not placebo controlled. Four randomized, placebo-controlled studies-the Systolic Hypertension in Europe (Syst-Eur) study, Study on Cognition and Prognosis in the Elderly (SCOPE), Systolic Hypertension in the Elderly Program (SHEP), and Perindopril Protection Against Recurrent Stroke Study (PROGRESS)-investigated the effects of antihypertensive agents on the incidence of dementia. The Syst-Eur study found that active treatment with nitrendipine, enalapril, and/or hydrochlorothiazide reduced the rate of dementia by 50% compared with placebo (p=0.05). The PROGRESS study showed that active treatment with perindopril and indapamide was associated with reduced cognitive decline compared with placebo (risk ratio 19%, p=0.01). In contrast, the SCOPE study (candesartan or hydrochlorothiazide vs placebo) and the SHEP trial (chlorthalidone, atenolol, or reserpine vs placebo) found no significant difference between the active treatment and placebo groups on the incidence of dementia. Some researchers have suggested that certain antihypertensive drug classes, such as angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, diuretics, and calcium channel blockers, may offer benefit in reducing dementia risk in addition to their blood pressure-lowering effect. Further prospective randomized studies comparing different antihypertensive classes are needed to provide more evidence regarding the effects of antihypertensive drugs on dementia risk and to determine whether certain antihypertensive classes provide greater benefits than others.

Determination of inositol hexanicotinate in rat plasma by high performance liquid chromatography with UV detection.

A HPLC method with UV detection at 262nm was developed to analyze inositol hexanicotinate in rat plasma. Plasma samples were extracted with an equal volume of acetonitrile, followed by dilution with mobile phase buffer (5mM phosphate buffer, pH 6.0) to eliminate any solvent effects. Inositol hexanicotinate and the internal standard (mebendazole) were separated isocratically using a mobile phase of acetonitrile/phosphate buffer (35:65, v/v, pH 6.0) at a flow rate of 1.0mL/min and a reverse-phase XTerra MS C(18) column (4.6mmx150mm, 3.5microm). The standard curve was linear over a concentration range of 1.5-100.0microg/mL of inositol hexanicotinate in rat plasma. The HPLC method was validated with intra- and inter-day precisions of 1.55-4.30% and 2.69-21.5%, respectively. The intra- and inter-day biases were -0.75 to 19.8% and 2.58-22.0%, respectively. At plasma concentrations of 1.5-100microg/mL, the mean recovery of inositol hexanicotinate was 99.6%. The results of a stability study indicated that inositol hexanicotinate was unstable in rat plasma samples, but was stable in acetonitrile extracts of rat plasma for up to 24h at 4 degrees C. The assay is simple, rapid, specific, sensitive, and reproducible and has been used successfully to analyze inositol hexanicotinate plasma concentrations in a pharmacokinetic study using the rat as an animal model.

Dissolution profiles of nonprescription extended-release niacin and inositol niacinate products.

PURPOSE: The dissolution profiles of nonprescription extended-release niacin and inositol niacinate products were studied using the prescription extended-release niacin, Niaspan, as a reference. METHODS: Seven nonprescription extended-release and 12 nonprescription inositol niacinate products were collected from community and online pharmacies in the United States. Extended-release Niaspan was used as a reference. Dissolution profiles were examined by the United States Pharmacopoeia dissolution test, using a paddle method. Release samples were removed every 30 minutes for up to 240 minutes. Niacin was quantified by high-performance liquid chromatography. RESULTS: Ten out of the 12 inositol niacinate products were capsules and 6 of the 7 extended-release formulations were tablets. During the initial 30-minute dissolution study of inositol niacinate products, free niacin was released to various degrees. One product achieved fast dissolution, with >30% cumulative release of niacin. The cumulative percentage of niacin released at 240 minutes of all inositol niacinate products was statistically different (p < 0.0001). The majority of these products reached a plateau of releasing niacin in one to two hours, which was maintained until the end of the study. Six out of the seven extended-release niacin products had extended-release profiles. Five products showed a statistically higher dissolution rate (p < 0.05) than that of Niaspan. CONCLUSION: Significant variations in dissolution profiles were noted among the 7 nonprescription extended-release and 12 nonprescription inositol niacinate products in vitro, and their dissolution rates were not comparable to that of the prescription extended-release niacin. Further studies are warranted to correlate such dissolution data with their in vivo efficacy.