Describing and Evaluating the Clinical Pharmacist's Role in a Canadian Multiple Sclerosis Clinic.

Background: The current approach to treatment of multiple sclerosis (MS) involves use of disease-modifying therapies to slow progression of the disease, as well as the symptomatic management of fixed neurological deficits. Although pharmacists are uniquely positioned to support MS care teams with all aspects of medication management, their presence is rare among MS ambulatory care teams in Canada. Objectives: To document the pharmacist's contributions and to evaluate the impact of the pharmacist's role following creation of a clinical pharmacist position in a Canadian MS clinic within a large, urban, university-affiliated, tertiary care centre. Methods: This study was conducted in 2 parts: a prospective, descriptive case study of the clinical pharmacist's role and a retrospective assessment of medication-related patient calls before and after implementation of the pharmacist position. Results: The pharmacist performed a variety of clinical activities, with the greatest proportions of time spent on patient care (63.3%), drug access research (15.7%), and development and review of internal documents (9.0%). Patient care primarily involved conducting patient assessments, making medication recommendations, and assisting patients with medication-related issues. The proportion of medication-related issues resolved remained similar at 92.9% before and 95.7% after implementation of the clinical pharmacist (p = 0.48). The median time to resolve medication-related issues was reduced from 4.1 to 2.9 days (p = 0.016) with pharmacist involvement. Conclusions: Pharmacists can support MS care teams through a variety of medication-related clinical activities aligned with their scope and expertise. The presence of a pharmacist on the MS care team significantly reduced turnaround times for resolving medication-related issues, improving the efficiency and timeliness of care.

Contexte: L'approche actuelle du traitement de la sclérose en plaques (SP) implique l'utilisation de traitements modificateurs de la maladie pour ralentir sa progression, ainsi que la prise en charge symptomatique des déficits neurologiques fixes. Bien que les pharmaciens occupent une position unique pour soutenir les équipes de soins de SP dans tous les aspects de la gestion des médicaments, leur présence est rare parmi les équipes de soins ambulatoires en SP au Canada. Objectifs: Documenter les contributions du pharmacien et évaluer l'incidence potentielle de son rôle après la mise en place d'un poste de pharmacien clinicien dans une clinique canadienne de SP au sein d'un grand centre de soins tertiaires urbain affilié à une université. Méthodologie: Cette étude a été menée en 2 parties : une étude de cas prospective et descriptive du rôle du pharmacien clinicien et une évaluation rétrospective des appels des patients liés aux médicaments avant et après la mise en place du poste de pharmacien. Résultats: Le pharmacien effectuait diverses activités cliniques, la plus grande proportion de temps étant consacrée aux soins aux patients (63,3 %), à la recherche sur l'accès aux médicaments (15,7 %) et à l'élaboration et à l'examen de documents internes (9,0 %). Les soins aux patients consistaient principalement à évaluer les patients, à formuler des recommandations en matière de médicaments et à aider les patients confrontés à des problèmes liés aux médicaments. La proportion de problèmes liés aux médicaments résolus est restée similaire, soit 92,9 % avant et 95,7 % après la mise en œuvre du pharmacien clinicien (p = 0,48). Le délai médian nécessaire pour résoudre les problèmes liés aux médicaments a été réduit de 4,1 à 2,9 jours (p = 0,016) avec la participation du pharmacien. Conclusions: Les pharmaciens peuvent soutenir les équipes soignantes de SP grâce à diverses activités cliniques liées aux médicaments, adaptées à leur portée et à leur expertise. La présence d'un pharmacien dans l'équipe de soins de la SP a considérablement réduit les délais d'exécution pour résoudre les problèmes liés aux médicaments, améliorant ainsi l'efficacité et la rapidité des soins.

Phenobarbital for the management of severe acute alcohol withdrawal (the PHENOMANAL trial): a pilot randomized controlled trial.

BACKGROUND: Benzodiazepines are considered first-line treatment for patients experiencing severe acute alcohol withdrawal syndrome (sAAWS). Although several medications have been evaluated as potential adjuvant treatments for sAAWS, barbiturates show particular promise. OBJECTIVE: In the PHENOMANAL trial, we will assess the feasibility of conducting an allocation-concealed, quadruple-blinded, randomized controlled trial (RCT) comparing symptom-triggered benzodiazepine therapy with either a single dose of adjuvant intravenous (IV) phenobarbital (7.5 mg/kg of ideal body weight) or a single dose of matching IV placebo for patients with sAAWS. METHODS: We will recruit adult patients from the Emergency Department, Intensive Care Unit, or hospital wards with a Clinical Institute of Withdrawal - Adult revised (CIWA-Ar) score of 16 or more after receipt of at least 60 mg of diazepam or equivalent within 16 h of diagnosis of sAAWS, and an anticipated need for hospitalization. We will randomize participants (n=39) in a 2:1 manner to treatment and placebo groups, respectively. The primary objective of the PHENOMANAL pilot trial will be to demonstrate our ability to recruit the desired population over the trial period. As secondary objectives, we will evaluate clinician compliance with the treatment protocols, assess crossover rates from the placebo arm to the treatment arm, and obtain preliminary estimates of treatment effect. All trial participants will be followed for 7 days or until hospital discharge. RELEVANCE: The PHENOMANAL trial is novel in investigating a new treatment for a common and understudied condition, repurposing an existing medication for a novel indication, and addressing an important evidence gap. Through conduct of the multidisciplinary pilot trial, we aim to advance methodology in acute care research through the use of a hybrid consent model and inform the design of a large-scale trial. TRIAL REGISTRATION: ClinicalTrials.gov Registration NCT03586089 ; first registered July 13, 2018.

Opioid stewardship: implementing a proactive, pharmacist-led intervention for patients coprescribed opioids and benzodiazepines at an urban academic primary care centre.

In 2017, almost 4000 Canadians died from opioid-related causes. Coadministration of opioids and benzodiazepines is a risk factor for overdose. Few studies have evaluated leveraging pharmacists to address opioid-benzodiazepine coprescribing. Our aim was to develop and test a role for pharmacists as opioid stewards, to reduce opioid and benzodiazepine doses in coprescribed patients. We conducted Plan-Do-Study-Act cycles between November 2017 and May 2018 across two primary care centre clinics. A third clinic acted as a control. Our intervention included a pharmacist: (1) identifying patients through medical record queries; (2) developing care plans; (3) discussing recommendations with physicians and (4) discussing implementing recommendations. We refined the intervention according to patient and physician feedback. At the intervention clinics, the number of patients with pharmacist developed care plans increased from less than 20% at baseline to over 60% postintervention. There was also a fourfold increase in the number of patients with an active opioid taper. At the control clinic, the number of patients with pharmacist developed care plans remained relatively stable at less than 20%. The number of patients with active opioid tapers remained zero. At the intervention clinics, mean daily opioid dose decreased 11% from 50.5 milligrams morphine equivalent (MME) to 44.7 MME. At the control clinic, it increased 15% from 62.3 MME to 71.4 MME. The number of patients with a benzodiazepine taper remained relatively stable at both the intervention and control clinics at less than 20%. At the intervention clinics, mean daily benzodiazepine dose decreased 8% from 9.9 milligrams diazepam equivalent (MDE) to 9.3 MDE. At the control clinic, it decreased 4% from 10.8 MDE to 10.4 MDE. A proactive, pharmacist-led intervention for coprescribed patients increased opioid tapers and decreased opioid and benzodiazepine doses. Future work will help us understand whether sustaining the intervention ultimately reduces rates of opioid-benzodiazepine coprescribing.

Descriptive study of homeless patients' perceptions that affect medication adherence.

PURPOSE: Results of a study to elucidate perceptions, attitudes, and beliefs about prescribed medications held by hospitalized patients who are homeless are reported. METHODS: A qualitative descriptive study involving semistructured interviews was conducted to gather information and characterize hospitalized homeless patients' views and attitudes regarding medication use, with a focus on medication nonadherence. Medication nonadherence has been shown to be a factor contributing to higher rates of emergency department visits, increased hospital lengths of stay, and increased healthcare costs in homeless populations. Interviews were conducted during patients' admissions to the internal medicine service of a tertiary care, inner-city hospital. Interviews were audio-recorded and transcribed. Data were analyzed using conventional qualitative content analysis to generate data-driven codes and themes. RESULTS: Twelve interviews were conducted (median patient age, 48.5 years). Eight patients (66.7%) were living in a shelter, and 11 (91.7%) had a mental illness. Patients were prescribed a median of 4 medications at the time of hospital admission. Four themes were identified: (1) a new appreciation of medications was acquired during hospitalization, (2) medications were perceived as necessary for maintaining health, (3) there was an interest in receiving medication education, and (4) concerns were expressed regarding medication adverse effects. CONCLUSION: In interviews conducted during hospital admission, homeless patients expressed positive perceptions about the necessity of their medications but also concerns about medication adverse effects. Interventions to improve adherence may be successful if directed toward addressing treatment-related concerns.

Integration of a clinical pharmacist into a Canadian, urban emergency department: a prospective observational study.

OBJECTIVE: To evaluate the clinical and cost implications generated by a newly integrated ED pharmacist in a Canadian urban, university-affiliated tertiary care hospital. METHODS: A pharmacist documented all interventions that took place over a 5-week period. Interventions were assessed by a review panel for clinical significance and probability of harm had the intervention not occurred. Direct medication cost and cost avoidance as a result of interventions were calculated. KEY FINDINGS: The ED pharmacist made 421 interventions during the study period, 204 (48%) interventions were accepted at the time they were presented to the prescriber. After review, 53.9% of interventions were considered significant, and 52.9% were given a probability of patient harm of ≥50% had the intervention not occurred. Interventions resulted in an increase in direct medication costs of $1270, but generated a cost avoidance of $160 709. The projected direct medication cost estimate for one year was $13 208 with a cost avoidance of over $1.6 million. CONCLUSION: The integration of a pharmacist into a Canadian ED resulted in patient care interventions that were assessed as clinically significant, with a substantial projected cost avoidance.

Evaluation of Standardization of Transfer of Accountability between Inpatient Pharmacists.

BACKGROUND: A compelling body of evidence supports the notion that transfer of accountability (TOA) improves communication, continuity of care, and patient safety. TOA involves the transmission and receipt of information between clinicians at each transition of care. Without a notification system alerting pharmacists to patient transfers, pharmacists' ability to seek out and complete TOA may be hindered. A standardized policy and process for TOA, with automated workflow, was implemented at the study hospital in 2015, to ensure consistency and timeliness of documentation by pharmacists. OBJECTIVE: To evaluate pharmacists' adherence to and satisfaction with the TOA policy and process. METHODS: A retrospective audit was conducted, using a random sample of individuals who were inpatients between June 2014 and February 2016. Transition points for TOA were identified, and the computerized pharmacy system was reviewed to determine whether TOA had been documented at each transition point. After the audit, an online survey was distributed to assess pharmacists' response to and satisfaction with the TOA policy and workflow. RESULTS: Before the TOA workflow was implemented, TOA documentation by pharmacists ranged from 11% (10/93) to 43% (48/111) of transitions. Eight months after implementation of the workflow, the rate of TOA documentation was 87% (68/78), exceeding the institution's target of 70%. Of the 32 pharmacists surveyed, most were satisfied with the TOA policy and agreed that the standardized workflow was simple to use, increased the number of TOAs provided and received, and improved the quality of completed TOAs. Respondents also indicated that the TOA workflow had improved patient care (mean score 4.09/5, standard deviation 0.64). CONCLUSIONS: The standardized TOA policy and process were well received by pharmacists, and resulted in consistent TOA documentation and a TOA documentation rate that exceeded the institutional target.

CONTEXTE: Un nombre imposant de données probantes viennent appuyer l'idée que le transfert de responsabilité (TDR) améliore la communication, la continuité des soins et la sécurité des patients. Le TDR consiste en la transmission et la réception d'information entre cliniciens à chaque transfert des soins. Sans système de notification informant les pharmaciens d'un transfert de patient, leur capacité de trouver et de réaliser un TDR pourrait être restreinte. Une politique et un processus normalisés de TDR, comprenant une automatisation du flux de travaux, ont été mis en place en 2015 dans l'hôpital à l'étude afin d'assurer que la consignation par les pharmaciens soit uniforme et opportune. OBJECTIF: Évaluer dans quelle mesure les pharmaciens respectent la politique et le processus de TDR, et en sont satisfaits. MÉTHODES: Un audit rétrospectif a été mené à l'aide d'un échantillon aléatoire composé de patients hospitalisés entre juin 2014 et février 2016. Les points de transition pour le TDR ont été recensés et le système informatique de la pharmacie a été consulté pour déterminer si le TDR avait été consigné à chaque point de transition. Après l'audit, un sondage en ligne a été envoyé aux pharmaciens pour évaluer leurs réactions à l'égard de la politique de TDR ainsi que du flux de travaux correspondant et pour connaître leur degré de satisfaction. RÉSULTATS: Avant la mise en place du flux de travaux associé au TDR, la fréquence de consignation du TDR par les pharmaciens variait entre 11 % (10/93) et 43 % (48/111) des transitions. Huit mois après la mise en place du flux de travaux, le taux était de 87 % (68/78), dépassant ainsi la cible de 70 % fixée par l'établissement. Parmi les 32 pharmaciens sondés, la plupart étaient satisfaits de la politique de TDR et ils estimaient que le flux de travaux normalisé était simple à suivre, qu'il augmentait le nombre de TDR reçus et fournis et qu'il améliorait la qualité des TDR menés à terme. Les pharmaciens ont aussi indiqué que le flux de travaux associé au TDR avait amélioré les soins aux patients (score moyen de 4,09/5, écart-type de 0,64). CONCLUSIONS: La politique et le processus normalisés de TDR ont été bien reçus par les pharmaciens et ont permis d'obtenir une harmonisation de la consignation du TDR et un taux de consignation du TDR qui dépassait la cible de l'établissement.

Anticonvulsant hypersensitivity syndrome: an update.

INTRODUCTION: Anticonvulsant hypersensitivity syndrome (AHS) is a rare but potentially life-threatening adverse drug reaction, primarily associated with phenytoin, phenobarbital and carbamazepine. It is characterized by a triad of fever, skin eruption and internal organ involvement (usually liver), which occur two to eight weeks after the initiation of therapy. Anticonvulsant hypersensitivity syndrome has been estimated to occur between 1 and 1000 and 1 in 10,000 exposures; however, its true incidence is unknown because of the variable presentation and inaccurate reporting. AREAS COVERED: This paper presents the incidence, epidemiology and pathogenesis of AHS, along with recommendations for its diagnosis and management. EXPERT OPINION: Avoidance of all aromatic anticonvulsants is recommended in patients who develop AHS with one of these agents, as there is a high degree of crossreactivity among all these agents. There are no universally recognized tests for the prediction of AHS due to aromatic anticonvulsants or lamotrigine. Yet genetic testing in a predictive sense would help guide the choice of an appropriate anticonvulsant medication. Other tests, using cellular surrogates, such as lymphocytes or platelets, have been used primarily for diagnostic testing and do not have the universal practicality afforded to genetic tests.

Abacavir hypersensitivity reaction: an update.

OBJECTIVE: To review the clinical features, risk factors, diagnosis, and management of abacavir hypersensitivity reaction (HSR). DATA SOURCES: A MEDLINE (1950-October 2007) and EMBASE (1980-October 2007) search using key words abacavir, HIV, human immunodeficiency virus, hypersensitivity reaction, HLA-B(*)5701, and patch tests was conducted. Conference abstracts and article bibliographies were reviewed to identify relevant studies. STUDY SELECTION AND DATA EXTRACTION: Studies that investigated the clinical and immunogenetic risk factors for abacavir hypersensitivity and the benefit of genetic screening, as well as articles that focused on the clinical presentation, assessment, and management of abacavir HSR, were considered for this review. DATA SYNTHESIS: Abacavir hypersensitivity is an immune-mediated reaction that typically occurs within the first 6 weeks of therapy. Signs and symptoms of abacavir HSR are nonspecific, which makes the diagnosis challenging, particularly in medically complex patients. Patch testing may improve the diagnosis and confirmation of abacavir HSR, but it remains experimental. Clinical management is aimed at supportive therapy and discontinuation of abacavir. Rechallenge with abacavir is contraindicated due to the risk of precipitating a life-threatening reaction. Appropriate patient education and a clear communication plan are essential for the safe use of this medication. Identification of patients at risk of developing abacavir hypersensitivity through routine genetic screening for human leukocyte antigen (HLA) HLA-B(*)5701 represents a significant advance in the field of pharmacogenomics, with an apparent 100% negative predictive value when used to screen for abacavir HSR. Preliminary data suggest that pharmacogenetic testing for HLA-B(*)5701 is cost effective. However, until routine testing is available, pharmacovigilance is necessary for the safe and effective use of abacavir. CONCLUSIONS: Serious adverse events associated with the use of abacavir can be avoided by appropriate recognition and management of the HSR. Screening patients for HLA-B(*)5701 prior to initiation of abacavir represents a tool to further decrease the risk of HSRs as well as unnecessary discontinuation of this drug.