Impact of Initiating a GLP1 Agonist and/or SGLT2 Inhibitor Therapy on De-Escalation and Discontinuation of Insulin and Diabetes Control When Managed by an Interprofessional Collaborative Team.

BACKGROUND: An FQHC in Denver, Colorado developed and implemented an interprofessional care model to collaboratively manage type 2 diabetes mellitus (T2DM). Utilizing the 340B program, the team protocolized ADA Guidelines to promote the early adoption of first-line medications, glucagon-like peptide1 receptor agonists (GLP1 RAs) and sodium-glucose cotransporter 2 inhibitors (SGLT2is) to improve patient outcomes. OBJECTIVES: To assess the impact of interprofessional collaborative management versus standard care on early initiation of a SGLT2i and/or GLP1 RA as first-line therapies to enhance (1) deprescribing of insulin, (2) reducing overbasalization of insulin through insulin de-escalation, and (3) effectively lowering A1C levels in adult primary care patients with T2DM. METHODS: This was a retrospective chart review of adult patients with T2DM who were initiated on a GLP1 RA and/or a SGLT2i. To determine the effects of initiating GLP1 RA and/or SGLT2i therapy on insulin usage and glycemic control, the total daily dose (TDD) of insulin before initiation was compared with the most recent TDD post-initiation to evaluate deprescribing. To determine the impact on overbasalization, pre-initiation and post-initiation insulin doses were evaluated. The effectiveness of GLP1 RA and/or SGLT2i in lowering A1C levels was determined by comparing the A1C prior to initiation with the A1C postinitiation. To evaluate the influence of interprofessional collaborative care on insulin deprescribing, overbasalization, and diabetes control, relevant measures were compared between patients receiving collaborative care versus standard care. RESULTS: Of the 60 total patients treated with insulin, 46.6% were deprescribed insulin, with a majority in the interprofessional collaborative group (93.1%) compared to standard care (6.9%). A total of 78.3% of patients benefited from a reduction in A1C following the initiation of a GLP1 RA and/or SGLT2i. The greatest A1C reduction was -2.9% in the group receiving metformin in addition to a GLP1 RA and a SGLT2i. Patients who received interprofessional collaborative care had an average A1c reduction of -2.9% compared to-1.1% with standard care. CONCLUSION: Most patients initially overbasalized on insulin experienced a reduction in overbasalization after initiating GLP1 RA and/or SGLT2i. There was a notable A1C reduction, de-escalation, and deprescribing of insulin in patients receiving interprofessional collaborative care.

Evaluation of a Conservative Pharmacist-led U-500R Insulin Management Protocol in the Primary Care Setting.

OBJECTIVE: The objective of this quality assurance study is to evaluate the impact of a conservative, pharmacist-led, U-500R insulin management protocol on diabetes control (A1c) and total daily dosage requirements between August 2016 and August 2018. METHODS: This was a retrospective chart review of adult patients, aged 18 to 79, with type 2 diabetes and managed with insulin, at 2 federally qualified healthcare clinics in Denver, Colorado. To determine if our conservative pharmacist-led U-500R insulin management protocol impacted efficacy and total daily dosage requirements when converting patients from U-100 to U-500R insulin, we compared the most effective dose of U-500R (defined as the total daily dose (TDD) of U-500R insulin at A1c goal or the lowest tolerated A1c) to the baseline A1c and TDD of U-100 insulin at time of conversion. RESULTS: Following conversion of U-100 to U-500R insulin, patients required an average of 21 fewer units of insulin with U-500R than U-100 and achieved an average A1c of 7.2% which reflected a reduction of 3.5 points from baseline. Five patients (62.5%) achieved A1c goal per ADA guidelines, and all patients achieved at least a 1.7 point reduction in A1c, with 1 patient achieving a 6.7 point reduction. Two patients (25%) were still in the process of U-500R titration at the time of data collection, and 1 patient (12.5%) did not achieve goal A1c while under pharmacy management at these clinics. Four of the five patients who achieved A1c goal did so with an overall reduction in total daily insulin dose (average of 57.5 units less than original U-100 dose) resulting in an average A1c decrease of 3.6 points.

Converting U-500 regular insulin to insulin detemir and insulin lispro in a patient undergoing dietary changes in preparation for bariatric surgery.

PURPOSE: The safe and effective conversion of human regular U-500 insulin (U-500R) to basal and bolus U-100 (insulin detemir and insulin lispro, respectively) in a patient undergoing a significant dietary change in preparation for bariatric surgery is described. SUMMARY: Conversion from U-100 to U-500R insulin has been described in the literature. There is, however, a paucity of information describing the reverse conversion (i.e., from U-500R to U-100 insulin). Whether converting to or from U-500R, patient safety is a primary concern. A 51-year-old Caucasian woman with a 10-year history of type 2 diabetes mellitus, hypertension, and gastroparesis who was scheduled to undergo bariatric surgery was converted from U-500R to insulin detemir and insulin lispro preoperatively while undergoing significant diet changes. The patient's blood glucose values, diet, and activity levels were closely monitored daily by the interprofessional team over a 10-day preoperative period during which her regular diet was changed to a very low-calorie, high-protein diet; insulin doses were adjusted accordingly. Throughout this process, the patient did not experience any major hypoglycemic episodes. Close collaboration among interprofessional team members and a strong partnership with the patient were considered key factors in the successful conversion of insulin therapy. CONCLUSION: Subcutaneous insulin therapy in a woman preparing for bariatric surgery was safely converted from U-500R to basal therapy with U-100 insulin detemir and with as-needed boluses of U-100 insulin lispro. This occurred as the patient switched from a regular diet to a low-calorie, high-protein diet.

Over-the-Counter Drugs to Avoid in Older Adults with Kidney Impairment.

Older adults (age 65 years or older) are at especially high risk of having adverse events from over-the-counter (OTC) drugs, and older adults who have kidney disease are at an even higher risk. These older adults with kidney impairment may need to completely avoid, or at the least reduce, their exposure to certain OTC products, such as nonsteroidal inhibitors. When older adults with kidney impairment are counseled about the safety of OTC drugs, they need to be made aware that some drugs may also require dose adjustments. Several categories of drugs that commonly require dosage changes include antihistamines, histamine-2 receptor antagonists, oral decongestants, codeine, and a few gastrointestinal drugs. Another concern is for the possibility of there being a drug-drug interaction between an OTC medication and a prescription drug. Careful consideration needs to be paid to the choice of drugs given to older adults. Patient education is essential to reduce the occurrence of adverse events.

Development of recommendations for dosing of commonly prescribed medications in critically ill obese children.

PURPOSE: The development and use of a decision support tool to help formulate recommendations for dosing of commonly prescribed medications in critically ill obese children are described. METHODS: Medications prescribed in 2010 to critically ill infants and children (younger than 18 years) were identified from the Pediatric Health Information System. The most commonly prescribed and therapeutically monitored medications were extracted. Supportive evidence for obesity dosing was identified through a standardized computerized search involving medical subject heading terminology and age filters using PubMed and Ovid. A usefulness scoring system was developed to rate the strength and applicability of the literature to critically ill obese children. A decision supporttool was then created to aid in the formulation of a dosing weight for each medication based on the usefulness score, published pharmacokinetic properties, clinical studies available in the primary literature, and consideration of clinical consequences of underdosing or overdosing. RESULTS: A total of 113 medications were evaluated, and 122 discrete citations, supporting 66 medications, were reviewed. Seventy-two percent of citations had general obesity dosing information, and 13% had pediatric-specific information. The overall mean usefulness score was 5.1±4.7 (median, 7). The decision support tool was incorporated to make final dosing weight recommendations for obese children. Ultimately, total body weight was recommended for 52 medications, adjusted weight for 43 medications, and ideal body weight for 18 medications. CONCLUSION: The inadequacy of obesity dosing information for most medications commonly ordered for children admitted to a pediatric intensive care unit led to the development of a decision support tool to aid in formulating dosing recommendations.

Design and Implementation of a Video-based Clinical Examination.

OBJECTIVES: To (1) describe the development of a Video-based Clinical Examination (VCE) as a formal testing format to evaluate student ability to make an accurate pharmaceutical assessment and recommendation, and (2) determine student perception of the VCE testing format. METHODS: Descriptive study of first-year pharmacy students. RESULTS: One hundred and twenty-nine students were included in the study. Students perceived that the VCE testing format provided a real life/interactive environment but felt rushed as the video segments of the patient/pharmacist interaction occurred quickly. IMPLICATIONS: Based on the findings of this project, we will continue to pursue further research related to validity, reliability and application of VCEs. However, the University of Colorado will continue to incorporate VCEs in the performance based evaluations in the Professional Skills Development 1 course, as it appears to be an effective stepping-stone for first-year students to begin developing their active listening, higher level learning and problem-solving skills. Results of this project will be shared with the faculty and curriculum committee at the University of Colorado School of Pharmacy to encourage further use and research of VCEs in other courses.

A comparison of pharmacy students' confidence and test performance.

OBJECTIVES: The objectives of this study were to estimate student retention of knowledge regarding the management of patients with hypertension and dyslipidemia, measure student clinical confidence, and identify the relationship between clinical confidence and actual performance on a knowledge assessment test. METHODS: This was a sequential cross-sectional study to evaluate knowledge retention and clinical confidence of second-year pharmacy students. To measure student clinical confidence, a 12-item clinical confidence questionnaire was administered. To measure student retention of knowledge, a 21-question knowledge assessment test was administered. At least 1 test question was related to each question asked in the clinical confidence questionnaire. RESULTS: One hundred eight students completed the study. The percentage of students correctly answering test questions decreased from a baseline of 70.4% +/- 5.8% to 60.9% +/- 5.8% four months later (p = 0.02) in spite of the students rating their clinical confidence from moderate to high in all areas. The proportion of students answering questions correctly was similar across the different levels of confidence. CONCLUSION: Overall, retention of knowledge appears to decline over a 4-month period of time. Furthermore, while students perceived moderate to high confidence, student knowledge did not match perceived confidence.

Similar medication compliance and control of dyslipidemia with simvastatin or atorvastatin in a staff-model HMO medical clinic.

OBJECTIVE: The primary objective of this study was to determine medication compliance rates and dyslipidemia control in a patient population receiving simvastatin or atorvastatin (statins) in a unique staff-model health maintenance organization (HMO). The secondary objective of this study was to measure the effect of gender and statin regimen on the success rate of dylipidemia control and medication compliance. METHODS: This was a retrospective chart review conducted for patients with a diagnosis of dyslipidemia who received monotherapy with a statin for cholesterol reduction. Patients received care at an outpatient clinic during a 12-month study period (December 1998 through December 1999). Patients were excluded if they did not have a low-density lipoprotein cholesterol (LDL-C) and high-density lipoprotein cholesterol (HDL-C) concentration obtained in 1999, did not have a statin prescription filled at least twice the during study period, discontinued statin therapy, or received a statin other than simvastatin or atorvastatin. Patient medication compliance was assessed using the medication possession ratio (MPR). Dyslipidemia control rates were determined according to the National Cholesterol Education Program (NCEP) Adult Treatment Panel (ATP) II guidelines. RESULTS: A total of 819 patients met inclusion criteria for study enrollment (55% male, 45% female). The mean age of the patients was 68.5 years. The mean MPR for the entire study group was 0.960.23. Men and women had similar mean MPR values (0.970.23 vs. 0.960.22, respectively; P=0.76). A nearly identical proportion of patients who received either atorvastatin or simvastatin achieved their LDL-C goal, 70.0% vs. 69.6%, respectively. Gender was not related to success rate, with 73.0% of women and 66.9% of men achieving their NCEPdirected LDL-C goal (P=0.06). The rate of attainment of ATP II LDL goal was 43.2% (92 of 213) for patients with goal < 100 mg/dL, 69.1% (226 of 327) for < 130, and 90.7% (252 of 279) for patients with goal < 160 mg/dL. CONCLUSIONS: Patients enrolled in a unique staff-model HMO who received either simvastatin or atorvastatin exhibited high medication compliance and dyslipidemia control rates. Gender did not affect medication compliance or attainment of LDL-C goal, and the success of achieving dyslipidemia control was not different between atorvastatin and simvastatin.