Effect of pharmacist interventions on reducing low-density lipoprotein cholesterol (LDL-C) levels: A systematic review and meta-analysis

Effect of pharmacist interventions on the management of overweight and obesity: A systematic review

BACKGROUND

Pharmacists are underused healthcare professionals who are well positioned to provide weight management interventions; however, a systematic review of the literature supporting the role of pharmacists in weight management is lacking.

OBJECTIVES

To conduct a systematic review to assess the body of evidence supporting the role of pharmacists in the management of obesity.

METHODS

A literature search of OVID MEDLINE, Embase, Web of Science, and CINAHL was conducted from inception through February 23, 2023, to identify studies involving pharmacist interventions for weight management. Included studies were retrospective or prospective studies reporting a change in body weight, body mass index (BMI), or waist circumference as a primary endpoint; and a weight management intervention involving a pharmacist. Studies were excluded if they did not report the desired outcomes, involved pediatric populations, or lacked a pharmacist in the intervention.

RESULTS

Twenty-nine studies met the eligibility criteria. A total of 6,423 study participants were enrolled with a mean BMI of 27 to 46 kg/m2. The included studies were conducted across 8 different countries with 15 from the United States. The primary approach was a prepost/quasi-experimental study design, typically conducted in community pharmacies. The pharmacists' role varied widely but mainly involved educational counseling as the pharmacist made medication recommendations in only 5 studies. Multidisciplinary collaboration was infrequent. All but 3 studies reported a significant improvement in the weight loss outcome of interest, although most study durations were less than 6 months. A critical appraisal of the 29 studies found the overall quality of the available studies to be relatively poor.

CONCLUSION

Pharmacist interventions for weight management were mostly effective in reducing body weight; however, more robust clinical trials with a comparator group and for longer duration are warranted. The pharmacist's role in managing weight loss medications also requires further study.

Lipid-lowering optimisation for secondary prevention vascular and diabetic foot patients in a pharmacist-led clinic

Patients attending vascular or diabetic foot clinics commonly have atherosclerotic disease, are at increased risk of cardiovascular disease (CVD), merit high-intensity lipid-modifying therapy to maintain secondary prevention targets and are often sub optimally treated in primary care. We set out to assess the impact of a pharmacist led lipid optimisation clinic in these patients in an area with high levels of social deprivation.

METHODS

We performed a clinical cohort study to assess the effectiveness of a pharmacist led clinic to optimise lipid lowering therapy by optimising of statin therapy and commencing additional lipid lowering therapy if applicable with monitoring of blood lipid profiles.

RESULTS

Of the 216 patients (166 (77%) on statins) triaged by the pharmacist, 175 (81%) had non-HDL cholesterol levels above the target value of 97 mg/dL (2.5 mmol/L) with a mean non-HDL cholesterol level of 135.73 mg/dL (3.51 mmol/L). Pre optimisation by the prescribing clinical pharmacist 41/216 (19%) patients were at target with a mean non-HDL cholesterol of 135.5 mg/dL improving to 92/137 (67%) patients achieving the target non-HDL cholesterol level with a mean post optimisation non-HDL cholesterol of 94.35 mg/dL (2.44 mmol/L), odds ratio for being at target 8.67 [95% CI 5.30-14.20]. The calculated LDL cholesterol levels (Friedewald) demonstrated a mean reduction of 35.19 [95% CI 29.23-41.38] mg/dL (0.91 [95% CI 0.76-1.07] mmol/l). Proportion on high intensity statin increased from 65 out of 166 (39%) to 129 of 170 (76%) at follow up O.R. 4.89 [3.06-7.82], equivalent to an NNT = 3.

CONCLUSIONS

A pharmacist led service in undertreated and clinically challenging vascular and diabetic foot patients in an area of high social deprivation produced significant improvements in utilization of high intensity statin and other lipid lowering therapies and attainment of lipid goals.

A meta-analysis of the impact of pharmacist interventions on clinical outcomes in patients with type-2 diabetes

OBJECTIVE

To evaluate the effects of pharmacist interventions in type-2 diabetes patients by collecting and evaluating literature.

METHODS

A systematic search was conducted across six databases, including CNKI, Wanfang Data, VIP, PubMed, Web of Science, and Cochrane Library, from January 2001 to January 2023. Randomized controlled trials evaluating the clinical outcomes of pharmacist interventions on type-2 diabetes patients were searched, and data were extracted and analysed by RevMan version 5.4 software.

RESULTS

A total of 35 studies involving 4827 patients were included. Meta-analysis demonstrated that pharmacist interventions had an influence on improving patients' HbA1c (MD=-0.70), LDL-C (MD=-5.51), SBP (MD=-4.58), DBP (MD=-1.90], BMI (MD=-0.47) and FBG (MD=-19.82), but there was no evidence from the study that pharmacist interventions could significantly improve HDL-C (MD=-0.61), TC (MD=-5.12) or TG (MD=-3.14). In addition, medication adherence was significantly improved.

CONCLUSION

Pharmacist interventions significantly improved HbA1c, BP, and LDL-C control levels, BMI, and medication adherence in type-2 diabetes patients, but there was no evidence from this study that pharmacist interventions significantly improved HDL-C, TC, or TG.

PRACTICE IMPLICATIONS

Effective pharmacist interventions are important to improve type-2 diabetes patients' clinical outcomes.

With Current Safety and Efficacy Data, Should Statins Be Made Available as Nonprescription Over-the-Counter Drugs?

PURPOSE OF REVIEW

Statins inhibit the enzyme 3-hydroxy-3-methylglutaryl-coenzyme A reductase in the liver and reduce atherosclerotic cardiovascular disease (ASCVD) risk by enhancing low-density lipoprotein (LDL) clearance from the circulation. In this review, we discuss their efficacy, safety, and real-world utilization to make a case for reclassifying statins as nonprescription over-the-counter drugs to improve access and availability with the overarching goal of increasing statin utilization in patients most likely to benefit from this class of therapy.

RECENT FINDINGS

Statin efficacy for reducing risk in primary and secondary ASCVD prevention populations as well as their safety and tolerability has been thoroughly investigated in large-scale clinical trials over the past 3 decades. Despite the overwhelming scientific evidence, statins are underutilized even among those at the highest ASCVD risk. We propose a nuanced approach to use statins as nonprescription drugs that leverages a multi-disciplinary clinical model. It integrates lessons learned from experiences outside the USA with a proposed Food and Drug Administration rule change that allows nonprescription drug products with an additional condition for nonprescription use.

Pharmacist-Led Programs to Increase Statin Prescribing: A Narrative Review of the Literature

Statins are lipid-lowing medications shown to reduce cardiovascular events and are recommended for specific patient populations at elevated risk of atherosclerotic cardiovascular disease (ASCVD). Despite the demonstrated efficacy of statins for reducing ASCVD risk, and guidance on which populations should receive statin therapy, a substantial portion of eligible patients are not prescribed statin therapy. Pharmacists have attempted to increase the number of eligible patients receiving appropriate statin therapy through a variety of interventions and across several clinical settings. In this article, we highlight multiple studies evaluating the effectiveness of pharmacist-led interventions to improve statin use. A total of seven studies were selected for this narrative review, demonstrating the effectiveness and barriers of different statin-initiation programs delivered by pharmacists to increase statin use in eligible patients. Among the interventions assessed, a combination of provider communicating and statin prescribing through collaborative drug therapy management (CDTM) appear to the be the most useful at increasing statin use. Pharmacists can significantly improve statin use rates among eligible patients through multiple intervention types and across different clinical settings. Further studies should evaluate continued statin adherence and clinical outcomes among patients served by pharmacists.

[Roles and impacts of the pharmacist in the management of insomnia: A literature review]

BACKGROUND

Insomnia is a common sleep disorder that affects a large portion of the population in a situational, recurrent, or chronic way. In Canada, it is estimated that 13% of the population suffers from it.

OBJECTIVE

The primary objective of this literature review is to identify and describe studies dealing with the role and impact of the management of insomnia by a pharmacist.

METHOD

PubMed®, EMBASE® and CINALH Complete were searched to extract articles published between January 1st, 1990 and May 28, 2020. Studies on the role and impact of management of insomnia by a pharmacist, in French and English, descriptive or quantitative, with or without control group were included. Articles that did not deal with insomnia as the primary topic or where insomnia is a secondary condition were excluded, conference abstracts and studies showing no concrete results. The following variables were extracted: author, type of study, duration, location, sample size and characteristics of participants, description of pharmacist interventions, limits and biases, outcomes assessed and results. The quality of the pharmacists' interventions description was evaluated with DEPICT2.

RESULTS

Our review identified eight articles published from 2006 to 2018 evaluating 14 types of outcomes and 41 separate outcomes. A total of 37% (7/19) of the quantitative outcomes had statistically significant positive results, regarding insomnia qualification, symptoms and adequate use. Six studies were conducted in community pharmacy. The quality score varied between 8 and 10 out of 11.

CONCLUSION

There is little data on the role and impact of the management of insomnia by a pharmacist. The pharmacist can have a positive impact, particularly when practicing in a community pharmacy. Given the limited data and the prevalence of insomnia, it appears relevant to invest in pharmaceutical evaluative research for this condition.

Closing the gap: Identification and management of familial hypercholesterolemia in an integrated healthcare delivery system

BACKGROUND

Familial hypercholesterolemia (FH) is an autosomal dominant genetic disorder that causes markedly elevated risk for early onset coronary artery disease. Despite availability of effective therapy, only 5-10% of affected individuals worldwide are diagnosed.

OBJECTIVE

To develop and evaluate a novel approach for identifying and managing patients with FH in a large integrated health system with a diverse patient population, using inexpensive methods.

METHODS

Using Make Early Diagnosis/Prevent Early Death (MEDPED) criteria, we created a method for identifying patients at high risk for FH within the Kaiser Permanente Northern California electronic medical record. This led to a pragmatic workflow for contacting patients, establishing a diagnosis in a dedicated FH clinic, and initiating management. We prospectively collected data on the first 100 patients to assess implementation effectiveness.

RESULTS

Ninety-three (93.0%, 95%CI: 86.1%-97.1%) of the first 100 evaluated patients were diagnosed with FH (median age = 38 years) of whom only 5% were previously recognized; 48% were taking no lipid-lowering therapy, and 7% had acute coronary symptoms. 82 underwent successful genetic testing of whom 55 (67.1%; 95%CI: 55.8%-77.1%) had a pathogenic mutation. Following clinic evaluation, 83 of 85 (97.6%) medication-eligible patients were prescribed combination lipid-lowering therapy. 20 family members in the healthcare system were diagnosed with FH through cascade testing.

CONCLUSIONS

This novel approach was effective for identifying and managing patients with undiagnosed FH. Care gaps in providing appropriate lipid-lowering therapy were successfully addressed. Further development and dissemination of integrated approaches to FH care are warranted.

Pharmacist-administered long-acting injectable PCSK9 service: A solution to improve patient access and adherence

In 2015, 2 proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, alirocumab and evolocumab, were approved by Food and Drug Administration (FDA). Both therapies reduce low-density lipoprotein cholesterol (LDL-C) by approximately 60% and reduce atherosclerotic cardiovascular disease (ASCVD) risk in patients with established ASCVD when added to background statin therapy. The initial cost of these medications was approximately $15,000 per year, which made them largely cost-prohibitive for many patients and the overall health care system. In recent years, the cost of both agents has been reduced by 60%, and they are no longer only available through specialty pharmacies. In addition, a third PCSK9-modulating therapy, inclisiran, is nearing FDA approval. Ongoing inclisiran therapy only requires biannual subcutaneous administration and achieves LDL-C reductions of approximately 50%. As the use of PCSK9-modulating therapies increases, models that improve adherence and persistence over time will be critical to ensure patient access and maximize their value. Community pharmacists can play an important role helping patients not only obtain access to these therapies by navigating previous authorization requests but also adhere to therapy by offering administration. Community pharmacists can also provide therapeutic monitoring using point-of-care lipid testing to ensure efficacy over time. Such a service could potentially be sustained through reimbursement for administration and point-of-care lipid testing. Given the cost of these therapies, innovative models involving community pharmacists will be necessary to ensure patient access to these preventive therapies and minimize overall costs to the health care system.