Impact of Dosing Conversion From Basal Insulin to Follow-On Insulin Glargine.

BACKGROUND: Several basal insulins have recently come to market including follow-on insulin glargine (Basaglar®). Currently, there is no real-world data published on the implications of conversion to Basaglar on dosing or glycemic control. OBJECTIVE: To identify differences in basal insulin dosing requirements, hemoglobin A1c (HbA1c), and incidence of hypoglycemia or weight gain when converting a patient to Basaglar from another basal insulin. METHODS: Single-center, retrospective chart review at an academic medical center. All patients prescribed Basaglar between December 15, 2016, and August 31, 2017 were included for review if converted from another basal insulin. PRIMARY OUTCOME: Difference in basal insulin requirements in both units/d and units/kilogram (kg)/d after conversion to Basaglar. SECONDARY OUTCOME: Change in HbA1c and weight. RESULTS: Mean basal insulin dose was 38.4 ± 26.3 units/d pre-conversion and 40.5 ± 29.8 units/d post-conversion (P = .031). Results were significant for patients with type 2 diabetes mellitus (T2DM; pre-conversion basal dose 34.6 ± 24.3 units/d; post-conversion basal dose 37.6± 29.0 units/d; P = .009). Weight-based dosing changed from 0.37 ± 0.25 units/kg/d pre-conversion to 0.39 ± 0.29 units/kg/d post-conversion (P = .056) and was significant for patients with T2DM (P = .040). A nonsignificant decrease in HbA1c was seen (-0.14% ± 1.24%; P = .142). There was no difference seen in weight (111.6 ± 46.3 kg vs 111.7 ± 46.9 kg; P = .662). CONCLUSION: Patients with diabetes require similar basal insulin doses upon conversion to Basaglar. Clinicians should monitor blood glucose closely during basal insulin transition.

Impact of virtual simulation in self-care therapeutics course on introductory pharmacy practice experience self-care encounters.

BACKGROUND AND PURPOSE: Pharmacy education programs use simulation to provide a realistic and safe environment for student learning. We studied whether incorporation of virtual simulation into a required first year self-care therapeutics course impacted frequency of interactions, self-reported student confidence, and preceptor-reported student performance during second-year community pharmacy introductory pharmacy practice experiences (IPPEs). EDUCATIONAL ACTIVITY AND SETTING: Virtual simulation cases using MyDispense were incorporated into a self-care therapeutics course in winter 2017. Students and preceptors were surveyed at the end of the fall semester community pharmacy IPPE. Data from IPPE experiences was compared with students who took the self-care therapeutics course in winter 2016 (control). FINDINGS: Students completed 30 virtual simulation cases and three cases as part of the final examination (n = 33). Students in the intervention group reported more patient care interactions during their IPPEs than students who did not complete virtual simulation cases, but there was no difference in self-reported confidence. Preceptors did not report any differences in the ability of students to complete over-the-counter medication interactions during IPPEs. SUMMARY: Cases were well received by students although they took longer to complete than initially anticipated. Students in the intervention group reported significantly more patient care interactions during IPPEs than those in the control group; however, there were no differences in self-reported confidence. Incorporation of virtual simulation was a sustainable change as the cases were able to be re-used the following year with minimal edits.

Implementation of a Palivizumab Order Panel to Decrease Inappropriate Use.

OBJECTIVE: Palivizumab is a monoclonal antibody used to prevent infection from respiratory syncytial virus (RSV) in certain patients who are at high risk for complications. A previous medication use evaluation (MUE) demonstrated 12% of our palivizumab use did not meet criteria for use. Prior to the start of the 2016-2017 RSV season, an order panel was implemented requiring prescribers to select the approved criterion for each patient prescribed palivizumab. In addition, our restriction policy changed to state that palivizumab use outside of preapproved criteria would require authorization from pediatric infectious diseases or the antimicrobial stewardship team. An MUE was conducted during the summer of 2017 to determine whether the order panel had an impact on appropriate prescribing of palivizumab. METHODS: Medication orders for patients who received palivizumab from December 2015 to April 2016 and from December 2016 to April 2017 were reviewed to determine the proportion of patients who did not meet the preapproved restriction criteria. Charts were reviewed to verify indications of palivizumab for each patient during both seasons. A χ2 test was used to compare the proportion of inappropriate orders between the 2 seasons. RESULTS: During the 2015-2016 RSV season, of the 80 palivizumab orders, there were 11 inappropriate administrations (13.8%). During the 2016-2017 RSV season, 70 orders were administered to patients, and 4 doses (5.7%) were inappropriate. The cost of palivizumab increased from year 1 to year 2 (acquisition cost of $2477.44 per 100 mg/mL vial during year 1, $2613.71 per 100 mg/mL vial during year 2). An estimated cost avoidance of $12,807.18 was observed due to the decrease in the number of inappropriate administrations of palivizumab following implementation of the order panel (n = 7). There was an overall reduction in the number of inappropriate orders from year 1 to year 2 (8.1%); however, the reduction was not significant (p = 0.102). CONCLUSIONS: Following the implementation of the order panel plus restriction policy, we observed a decrease in the proportion of inappropriate doses that were administered from the preimplementation period to the postimplementation period, which also resulted in a cost avoidance of approximately $13,000.

A Comprehensive Functional Assessment of Carboxylesterase 1 Nonsynonymous Polymorphisms.

Carboxylesterase 1 (CES1) is the predominant human hepatic hydrolase responsible for the metabolism of many clinically important medications. CES1 expression and activity vary markedly among individuals; and genetic variation is a major contributing factor to CES1 interindividual variability. In this study, we comprehensively examined the functions of CES1 nonsynonymous single nucleotide polymorphisms (nsSNPs) and haplotypes using transfected cell lines and individual human liver tissues. The 20 candidate variants include CES1 nsSNPs with a minor allele frequency >0.5% in a given population or located in close proximity to the CES1 active site. Five nsSNPs, including L40Ter (rs151291296), G142E (rs121912777), G147C (rs146456965), Y170D (rs148947808), and R171C (rs201065375), were loss-of-function variants for metabolizing the CES1 substrates clopidogrel, enalapril, and sacubitril. In addition, A158V (rs202121317), R199H (rs2307243), E220G (rs200707504), and T290M (rs202001817) decreased CES1 activity to a lesser extent in a substrate-dependent manner. Several nsSNPs, includingL40Ter (rs151291296), G147C (rs146456965), Y170D (rs148947808), and R171C (rs201065375), significantly reduced CES1 protein and/or mRNA expression levels in the transfected cells. Functions of the common nonsynonymous haplotypes D203E-A269S and S75N-D203E-A269S were evaluated using cells stably expressing the haplotypes and a large set of the human liver. Neither CES1 expression nor activity was affected by the two haplotypes. In summary, this study revealed several functional nsSNPs with impaired activity on the metabolism of CES1 substrate drugs. Clinical investigations are warranted to determine whether these nsSNPs can serve as biomarkers for the prediction of therapeutic outcomes of drugs metabolized by CES1.