A Systematic Review of Interventions Implemented by Pharmacy Programs to Improve Postgraduate Residency Placement.

OBJECTIVE: This systematic review aims to identify the impact of interventions implemented by pharmacy programs to support students pursuing postgraduate residency training. METHODS: We conducted a literature search through March 8, 2022 to identify articles that studied an intervention made by a pharmacy program aiming to prepare students to qualify for a postgraduate residency position. Data were collected to describe each study's methods, the included population, and outcomes and to evaluate study risk of bias. FINDINGS: Twelve studies met our inclusion criteria. The evidence base is limited to observational data with significant risk of bias. Pharmacy programs use various strategies to deliver training to students opting for the residency application process: elective courses, multiyear curricular tracks, introductory pharmacy practice experiences (IPPEs), and organized professional development events. Participation in these interventions was found to be associated with higher residency match rates, with exception of IPPE where match rates were not evaluated as an outcome. Curricular tracks and multicomponent professional development events were found to be associated with the largest improvement in match rates. Participation in electives or multicomponent professional development was found to be associated with improved student knowledge and confidence in interviews. Multicomponent professional development was also found to be associated with student preparedness for the match process. Curricular tracks and IPPE were found to be associated with improved student knowledge, whereas mock interviews were associated with improved student confidence. SUMMARY: Pharmacy schools support preparation of students for the residency application and interview process in a variety of ways. The current evidence does not support one strategy to be more effective than another. Until additional evidence emerges to guide decisions, schools should select training programs based on balancing the need to support student professional development with resources and workload.

The clinical utility of newer antidepressant agents: Understanding the role in management of MDD.

Whereas MDD is characterized in part by changes in mood, other symptoms can also cause significant impairment, including sexual dysfunction, cognitive impairment, and fatigue. Newer antidepressants are explored with the goal of more optimally treating these non-mood-related symptoms of MDD. The 3 oral antidepressants that have been FDA-approved most recently include vortioxetine, vilazodone, and levomilnacipran. Unique features of these antidepressants are explored through 3 patient cases.

A false positive fentanyl result on urine drug screen in a patient treated with ziprasidone.

BACKGROUND: The objective of this case report is to highlight the possibility of the second-generation antipsychotic ziprasidone causing a false positive result for fentanyl on a urine drug screen (UDS). CASE SUMMARY: A 70-year-old female was admitted to an inpatient psychiatric unit for treatment of a manic episode of bipolar I disorder. She had no previous history of a substance use disorder (SUD) and had no previous positive results on UDS tests spanning an 8-year period. However, her UDS obtained in the emergency department (ED) was positive for fentanyl. The patient adamantly denied that she had ingested anything other than her prescribed medications. Her outpatient psychiatric provider also endorsed that she had no previous known history of an SUD. It was suspected that the patient's treatment with ziprasidone prior to admission and in the ED contributed to this positive fentanyl result. PRACTICE IMPLICATIONS: It has been established that risperidone may cause false positive fentanyl results on UDS. Due to structural similarities, ziprasidone may also cause this same result. As clinicians become more aware of the ubiquity of fentanyl in the illicit drug supply, it is imperative that clinicians also consider limitations of the currently available UDSs.

Review of the Efficacy and Safety of Lemborexant, a Dual Receptor Orexin Antagonist (DORA), in the Treatment of Adults With Insomnia Disorder.

OBJECTIVE: To provide an overview of the efficacy and safety of lemborexant in the treatment of insomnia disorder by assessing the currently available literature. DATA SOURCES: A literature search of PubMed was performed (2010 to March 2021) using the following search terms: lemborexant, sleep, orexin. STUDY SELECTION AND DATA EXTRACTION: All relevant English-language studies were reviewed and considered, with a focus on phase 3 trials. DATA SYNTHESIS: The efficacy and safety of lemborexant in the treatment of insomnia disorder in adults was demonstrated in 2 phase 3 trials. Lemborexant significantly reduced latency to persistent sleep compared with placebo. The first study also demonstrated a significant reduction compared with the active control zolpidem ER. Somnolence and headache were relatively common, but the marked adverse effects associated with other medications commonly used to treat insomnia, such as cognitive and psychomotor impairment and complex sleep-related behaviors, were not observed. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE: Although nonpharmacological therapy is considered first-line treatment for insomnia disorder, pharmacological treatment is most commonly utilized. Lemborexant is a viable pharmacological treatment option for patients who are unable to tolerate the adverse effects associated with the most commonly prescribed medications for insomnia, such as benzodiazepines and sedative-hypnotics (Z drugs). This is especially true for geriatric patients, who may be more sensitive to these adverse effects. CONCLUSION: Lemborexant can be recommended to treat insomnia disorder when pharmacological treatment is warranted. It has demonstrated efficacy in clinical trials and is likely better tolerated than most currently available treatment options.

Pharmacologic Similarities and Differences Among Hallucinogens.

Hallucinogens constitute a unique class of substances that cause changes in the user's thoughts, perceptions, and mood through various mechanisms of action. Although the serotonergic hallucinogens such as lysergic acid diethylamide, psilocybin, and N,N-dimethyltryptamine have been termed the classical hallucinogens, many hallucinogens elicit their actions through other mechanisms such as N-methyl-D-aspartate receptor antagonism, opioid receptor agonism, or inhibition of the reuptake of monoamines including serotonin, norepinephrine, and dopamine. The aim of this article is to compare the pharmacologic similarities and differences among substances within the hallucinogen class and their impact on physical and psychiatric effects. Potential toxicities, including life-threatening and long-term effects, will be reviewed.

Health System Pharmacist Protocol for Myocarditis Monitoring in Clozapine-Naïve Inpatients-Two Years' Experience.

OBJECTIVE: To describe the implementation and efficacy of a pharmacist-driven clozapine myocarditis monitoring protocol including 2 cases of clozapine-induced myocarditis identified using this protocol. METHODS: In February 2015, the health system formulary committee approved changes to an existing pharmacist-driven protocol to allow for myocarditis monitoring in patients initiated on clozapine therapy based on an algorithm published by Ronaldson et al in 2011. The monitoring includes the measurement of C-reactive protein (CRP; via high-sensitivity CRP [hsCRP] serum test) and troponin at baseline and then weekly for 4 weeks. Patients initiated on clozapine therapy between March 2015 and February 2017 and monitored according to the aforementioned protocol are described in this article. RESULTS: A total of 38 patients were initiated on clozapine therapy during the specified data collection period. Of these 38 patients, 4 screened positive for early signs of myocarditis according to the monitoring protocol, and 2 of those 4 patients were confirmed by cardiology consultation to have clozapine-induced myocarditis. Both of these patients experienced a full cardiac recovery upon discontinuation of clozapine. CONCLUSION: A pharmacist-driven myocarditis monitoring protocol for clozapine-naïve patients may help to identify early signs of clozapine-induced myocarditis and therefore mitigate potentially life-threatening complications by prompting early discontinuation of the inciting drug.

Clozapine-induced pulmonary embolism in a patient with minimal pre-existing risk factors.

OBJECTIVES: Although the risk of antipsychotic-induced venous thromboembolism (VTE) has been definitively established, guidelines recommending prophylactic anticoagulation do not yet exist. Several algorithms have been proposed that suggest possible prophylaxis with an anticoagulant medication on the basis of pre-existing VTE risk factors. We present a case of antipsychotic-induced VTE despite the patient's low-risk status so that practitioners may better understand which factors may or may not constitute a major risk in this population when making a determination about prophylactic anticoagulation. CASE SUMMARY: We present a patient case of a 56-year-old man with schizoaffective disorder who was treated with clozapine at an inpatient psychiatric unit. Although he would be classified as low risk for VTE on the basis of the proposed algorithms, he experienced a pulmonary embolism by day 17 of treatment and required transfer to a medical unit. This patient displayed sensitivity to other adverse effects associated with clozapine during his treatment course, including tachycardia, sialorrhea, enuresis, and bowel obstruction. PRACTICE IMPLICATIONS: Many of the known risk factors for antipsychotic-induced VTE were not present in this patient, including immobility, hyperprolactinemia, and coagulation abnormalities. The recent initiation of clozapine and obesity seem to be the only identified risk factors, although malignancy and abnormal antiphospholipid antibody levels were not able to be ruled out. It is difficult to determine if this patient experienced a VTE owing to a relatively high degree of sensitivity to clozapine, as evidenced by the myriad of other adverse effects that he experienced. This case highlights the need to determine true antipsychotic-induced VTE risk factors, including evaluation of comorbid adverse effects that occur in addition to the VTE. This information will help to guide future decision-making regarding the risk versus benefit of providing prophylactic anticoagulation for patients during initiation of antipsychotic treatment.