A Pharmacist-Led Process to Monitor Discrepant Urine Drug Screen Results.

Background: A urine drug screen (UDS) is a common risk-mitigation strategy tool for prescribing controlled substances, particularly opioids. Due to their complexity, UDS results can be misinterpreted and thereby have profound impacts on the patient-clinician relationship. From 2021 to 2022, a clinical dashboard to review potentially discrepant UDS results-based on a comparison of the results to the patient's medication list-was made available by the Veterans Health Administration. Methods: This quality improvement project implemented a process for weekly clinical pharmacist reviews of the UDS dashboard. Significant discrepant UDS results were reviewed in depth. From June 2022 through September 2022, 700 UDSs were performed and 60 patients had significant discrepancies that warranted in-depth review. Results: Pharmacist interventions during the review included 39 collaborations with medication prescribers to discuss follow up (65%), 25 queries to a prescription drug monitoring program (42%), and 9 confirmatory UDS on the original sample (15%). In-depth reviews were required for about 4 patients weekly, with a mean length of 14 minutes. Conclusions: A pharmacist-led process to monitor discrepant UDS results led to opportunities for collaboration with prescribers and positively impacted confirmatory testing at a rural veterans affairs health system.

Patient Case Report: Gabapentin-Induced Hypoglycemia.

PURPOSE: Gabapentin is an analog of gamma-aminobutyric acid (GABA), but its complete mechanism is not well understood. Common adverse effects from gabapentin include somnolence, sedation, and dizziness. Hyperglycemia is listed as a possible adverse drug reaction in the labeling. Case reports describe hypoglycemia in patients with diabetes, peritoneal dialysis, and/or incomplete medication records. The following case report details a hypoglycemia episode as a potential result of a gabapentin use in a patient without diabetes. SUMMARY: A 47-year old, 68 kg, white female presented to the emergency department with altered mental status. Her blood glucose level was 33 mg/dL. Gabapentin was started 1 week prior to the hypoglycemia episode. Her past medical history, concomitant medications, and other laboratory findings were not likely causes of her severe hypoglycemia. CONCLUSION: Gabapentin appears to have effects on several voltage-gated calcium channels. Hypoglycemia may be due to gabapentin binding to the alpha2delta subunit of the calcium channels in the pancreas. Future research should investigate gabapentin and the potential for hypoglycemia.

Patient Case Report: Memantine for the Treatment of Occipital Neuralgia.

Occipital neuralgia (ON) is described as a shooting, stabbing pain in the posterior part of the scalp that involves the occipital nerve. The epidemiology and pathophysiology are uncertain, but ON is considered distinct from other headache types. At the time of this writing, memantine for the treatment of ON has not been described in the literature. The following details a case report of successful treatment of ON with memantine. A 64-year-old, 91-kg, White man presented with severe headache associated with ON. Previous trials of oral medications, acupuncture, or physical therapy did not provide relief. The patient reported 15 ON headache days per month, use of 18 sumatriptan tablets per month, and daily use of as-needed ibuprofen. Because of inadequate relief of ON from other treatments, memantine was started. After titration to memantine 10 mg by mouth twice daily, the patient reported he was "100% headache free" from his ON pain. The patient tolerated memantine well without adverse effects. This case report displays safe, effective, and novel treatment of ON with memantine 10 mg by mouth daily, twice daily. The known safety, tolerability, and pharmacodynamics of memantine may warrant its off-label use in future studies exploring efficacy in ON.

Cyclic vomiting syndrome: diagnostic approach and current management strategies.

Cyclic vomiting syndrome (CVS) is a disorder characterized by episodes of nausea and vomiting lasting for 1-5 days followed by asymptomatic periods. The etiology of CVS is unknown, but it shares similar characteristics to migraine headaches. CVS is generally classified as having four phases: prodromal, acute/vomiting/hyperemesis, recovery, and remission/interepisodic. Current management strategies include trigger avoidance, abortive and prophylactic medication therapies, and supportive care. The goal of therapy for the remission phase is prophylaxis of further episodes. Antidepressant, antiepileptic, and antimigraine medications show an overall reduction or remission of CVS symptoms in more than 70% of patients. This article provides a summary of diagnostic strategies and reviews current management strategies for CVS.