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Ballister B, Hernandez RL, Quffa LH, Franck AJ. Clinical Pharmacy Specialist Collaborative Management and Prescription of Diabetes Medications with Cardiovascular Benefit. J Pharm Pract 2024; 37:435-441. [PMID: 36469659 DOI: 10.1177/08971900221144399] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2024]
Abstract
Background: Involvement of Clinical Pharmacy Specialists (CPS) in the care of patients with diabetes mellitus (DM) has been demonstrated to be beneficial. Whether this positive impact applies to increased use of cardiovascular risk-reducing medications is less well established. Objective: To determine the association of CPS co-management on the prescription of diabetes medications with proven cardiovascular benefits for patients with DM and established cardiovascular disease in the primary care setting. Methods: This retrospective cohort study evaluated patients in a Veterans Affairs health-system in primary care settings from February 1, 2019, through January 31, 2020. Patients were included if they had type 2 DM treated with at least one medication and had CVD. Patients were grouped into two cohorts for comparison, those with CPS co-management and those without. The primary outcome was the proportion of patients in each group with new prescriptions for empagliflozin or liraglutide initiated during the study timeframe. Results: In total, 8058 patients were found eligible for inclusion in the study. Clinical co-management by a CPS was provided to 2099 patients. Study medications were prescribed, approved, and initiated in 596 patients during the study period, including 391 (18.6%) in the CPS group and 205 (3.4%) in the non-CPS group (P < .001). Conclusion: This study showed CPS involvement is associated with increased prescribing of diabetes medications with proven cardiovascular benefits.
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Affiliation(s)
- Briana Ballister
- VA North Florida South Georgia Veterans Health System, Gainesville, FL, USA
| | - Rebecca L Hernandez
- VA North Florida South Georgia Veterans Health System, Gainesville, FL, USA
- Washington DC VA Medical Center, Washington, DC, USA
| | - Lieth H Quffa
- VA North Florida South Georgia Veterans Health System, Gainesville, FL, USA
| | - Andrew J Franck
- VA North Florida South Georgia Veterans Health System, Gainesville, FL, USA
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Al-Hindi B, Mohammed MA, Mangantig E, Martini ND. Prevalence of sodium-glucose transporter 2 inhibitor-associated diabetic ketoacidosis in real-world data: A systematic review and meta-analysis. J Am Pharm Assoc (2003) 2024; 64:9-26.e6. [PMID: 37844733 DOI: 10.1016/j.japh.2023.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 09/30/2023] [Accepted: 10/09/2023] [Indexed: 10/18/2023]
Abstract
BACKGROUND The U.S. Food and Drug Administration (FDA) revised the labels of sodium-glucose transporter 2 (SGLT2) inhibitors in December 2015 to inform users regarding the risk of diabetic ketoacidosis (DKA). As more drugs of this class are approved and their indications are expanded, this serious adverse effect has been increasingly reported. OBJECTIVE This review evaluated observational studies to inform the prevalence of SGLT2-inhibitor-associated DKA compared with other antihyperglycemic agents. METHODS A systematic review was conducted in PubMed and EMBASE until 19 July 2022 (PROSPERO: CRD42022385425). We included published retrospective cohort active comparator/new user (ACNU) and prevalent new user studies assessing SGLT2-inhibitor-associated DKA prevalence in adult patients with type 2 diabetes mellitus (T2DM) against active comparators. We excluded studies which lacked 1:1 propensity score matching. The JBI Checklist for Cohort Studies guided the risk-of-bias assessments. Meta-analysis was conducted based on the inverse variance method in R software. RESULTS Sixteen studies with a sample of 2,956,100 nonunique patients met the inclusion criteria. Most studies were conducted in North America (n = 9) and adopted the ACNU design (n = 15). Meta-analysis of 14 studies identified 33% higher DKA risk associated with SGLT2 inhibitors (HR = 1.33, 95% CI: 1.14-1.55, P < 0.01). Meta-regression analysis identified the study location (P = 0.02), analysis principle (P < 0.001), exclusion of chronic comorbidities (P = 0.007), and canagliflozin (P = 0.04) as significant moderator variables. CONCLUSIONS Despite limitations related to heterogeneity, generalizability, and misclassification, the results of this study show that SGLT2 inhibitors increase the prevalence of DKA among adult T2DM patients in the real world. The findings supplement evidence from randomized controlled trials (RCTs) and call for continued vigilance.
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Trueman C, Shin E, Donovan A, McAdam-Marx C, Coan C. Pharmacist impact on evidence-based prescribing of diabetes medications in patients with clinical atherosclerotic cardiovascular disease. J Manag Care Spec Pharm 2023; 29:1275-1283. [PMID: 38058135 PMCID: PMC10776252 DOI: 10.18553/jmcp.2023.29.12.1275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/08/2023]
Abstract
BACKGROUND Including pharmacists on care teams of patients with type 2 diabetes (T2D) has been shown to promote guideline-based prescribing and improve glycemic control, lowering risks of adverse cardiovascular outcomes. Evidence is lacking regarding whether including pharmacists on the care team is associated with the prescribing of GLP-1 receptor agonists (GLP-1 RA) and SGLT-2 inhibitors (SGLT-2i) recommended for use in patients with T2D and atherosclerotic cardiovascular disease (ASCVD). OBJECTIVE To assess the association between having a pharmacist on the primary care team of patients with T2D and ASCVD and being prescribed a guideline-recommended GLP-1 RA or SGLT-2i. METHODS A cross-sectional analysis of patients with T2D and ASCVD seen by primary care providers at an academic medical center between June 2019 and May 2020 was completed. Patients with prescriptions for GLP-1 RA or SGLT-2i with evidence of cardiovascular benefit were identified and compared between those with pharmacist care vs usual care using multivariable log-binominal regression analyses. RESULTS Of 1,497 included patients, 1,283 (85.7%) were in the usual care group (mean age 68.9 years, hemoglobin A1c 7.6%) and 214 (14.3%) in the pharmacist care group (mean age 64.5 years, A1c 9.0%). Of the pharmacist care group, 50.5% were prescribed a GLP-1 RA or SGLT-2i with cardiovascular benefit vs 17.9% in the usual care group (P < 0.001). In multivariable analyses controlling for A1c and other potential confounders, those in the pharmacist care group were 2.15 times as likely to have been prescribed a GLP-1 RA or SGLT-2i than those in the usual care group (adjusted risk ratio 2.15, 95% CI = 1.83-2.52; P < 0.001). CONCLUSIONS These data provide preliminary evidence that integrating pharmacists into patient care teams is associated with increased prescribing of guideline-recommended treatment with GLP-1 RA and SGLT-2i in patients with T2D and ASCVD, yet there is room for improvement in prescribing these agents to patients with T2D and ASCVD.
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Affiliation(s)
- Caressa Trueman
- Department of Pharmacy and Nutrition Care, Nebraska Medicine, Omaha
| | - Emily Shin
- Department of Pharmacy and Nutrition Care, Nebraska Medicine, Omaha
| | - Anthony Donovan
- Department of Pharmacy and Nutrition Care, Nebraska Medicine, Omaha
| | - Carrie McAdam-Marx
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Nebraska Medical Center, Omaha
| | - Canice Coan
- Department of Pharmacy and Nutrition Care, Nebraska Medicine, Omaha
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Hirsh BJ, Hirsch JS, Hmoud H, Weintraub S, Cha A, Lesser M, Huang X, Xie YYS, Nahrwold R, Joshua J, Scanlon J, Galella T, Singh V, Gianos E. A system approach to improving guideline-directed therapy for cardio-renal-metabolic conditions: The "beyond diabetes" initiative. Am J Prev Cardiol 2023; 16:100608. [PMID: 37822579 PMCID: PMC10562667 DOI: 10.1016/j.ajpc.2023.100608] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 08/29/2023] [Accepted: 09/24/2023] [Indexed: 10/13/2023] Open
Abstract
Objective Despite demonstrating improvements in cardiovascular disease, kidney disease, and survival outcomes, guideline-directed antihyperglycemic medications such as sodium-glucose cotransporter 2 inhibitors (SGLT2i) and glucagon-like-peptide-1 receptor agonists (GLP1-RA), are underutilized. Many obstacles constrain their use including lack of systematic provider and patient education, concern for medication side effects, and patient affordability. Methods We designed a multimodality, systems-based approach to address these challenges with the goal of increasing medication utilization across the largest healthcare system in New York State. This multispecialty collaborative included provider and patient education, an electronic health record-enabled platform to identify eligible patients, and access to pharmacists for medication guidance and addressing insurance coverage barriers. Surveys were administered following grand rounds lectures and knowledge-based questionnaires were given before and after case-based sessions for housestaff, with results analyzed using a two-sided Student's t-test. Rates of first prescriptions of SGLT2i/GLP1-RA in combined and individual analyses were compared between the pre- and post-education periods (6 months prior to 3/31/2021 and 6 months post 8/19/2021), and the change in prescriptions per 100 eligible-visits was assessed using the incidence density approach. Results Among grand rounds participants, 69.3% of respondents said they would make changes to their clinical practice. Knowledge increased by 14.7% (p-value <0.001) among housestaff following case-based sessions. An increase in SGLT2i/GLP1-RA prescribing was noted for eligible patients among internal medicine, cardiology, nephrology, and endocrinology providers, from 11.9 per 100 eligible visits in the pre-education period to 14.8 in the post-education period (absolute increase 2.9 [24.4%], incidence risk ratio 1.24 [95% CI 1.18-1.31]; p-value <0.001). Increases in prescribing rates were also seen among individual medical specialties. Conclusions Our "Beyond Diabetes" initiative showed an improvement in provider knowledge-base and was associated with a modest, but statistically significant increase in the use of SGLT2i and GLP1-RA throughout our healthcare system.
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Affiliation(s)
- Benjamin J. Hirsh
- Department of Cardiology, Sandra Atlas Bass Heart Hospital, Manhasset, NY, United States
- Department of Cardiology, Donald and Barbara Zucker School of Medicine at Hofstra/ Northwell, Hempstead, NY, United States
| | - Jamie S. Hirsch
- Division of Kidney Diseases and Hypertension, Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
- North Shore University Hospital, Manhasset, NY, United States
| | - Hosam Hmoud
- Lenox Hill Hospital, New York, NY, United States
| | | | - Agnes Cha
- Department of Ambulatory Pharmacy Services, Northwell Health, Lake Success, NY, United States
| | - Martin Lesser
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
- Biostatistics Unit, Office of Academic Affairs, Northwell Health, New York, NY, United States
| | - Xueqi Huang
- Biostatistics Unit, Office of Academic Affairs, Northwell Health, New York, NY, United States
| | - Yan Yan Sally Xie
- Division of Endocrinology, Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - Rachel Nahrwold
- Department of Cardiology, Lenox Hill Hospital, New York, NY, United States
| | - John Joshua
- Global Strategic Partnerships, Northwell Health, New York, NY, United States
| | - Jennifer Scanlon
- Global Strategic Partnerships, Northwell Health, New York, NY, United States
| | - Thomas Galella
- Department of Healthcare Delivery Analytics, Northwell Health, New York, NY, United States
| | - Varinder Singh
- Department of Cardiology, Donald and Barbara Zucker School of Medicine at Hofstra/ Northwell, Hempstead, NY, United States
- Department of Cardiology, Lenox Hill Hospital, New York, NY, United States
| | - Eugenia Gianos
- Department of Cardiology, Donald and Barbara Zucker School of Medicine at Hofstra/ Northwell, Hempstead, NY, United States
- Department of Cardiology, Lenox Hill Hospital, New York, NY, United States
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Xiao J, Wang Q, Tan S, Chen L, Tang B, Huang S, Zhou Y, Xu P. Analysis of patient medication compliance and quality of life of physician-pharmacist collaborative clinics for T2DM management in primary healthcare in China: A mixed-methods study. Front Pharmacol 2023; 14:1098207. [PMID: 37033638 PMCID: PMC10080104 DOI: 10.3389/fphar.2023.1098207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 03/16/2023] [Indexed: 04/11/2023] Open
Abstract
Background: Physician-pharmacist collaboration is a well-established care mode for the management of type 2 diabetes mellitus (T2DM) in developed countries, but no study has been conducted in primary healthcare in China. This study aims to evaluate the effects of physician-pharmacist collaborative clinics to manage T2DM in primary healthcare in China, and to better understand the factors influencing the implementation of physician-pharmacist collaborative clinics. Methods: Two hundred and sixty-seven patients involved in a 12-month randomized controlled trial were assigned to physician-pharmacist collaborative clinics and usual clinics, completing surveys regarding medication compliance, quality of life (QoL) and care-seeking behavior at the baseline, 3rd, 6th, 9th and 12th month respectively, and diabetes knowledge at baseline and 12th month. A sample of twenty-two Patients, nine physicians and twelve pharmacists participated in semi-structured face-to-face interviews. The quantitative and qualitative data was integrated by triangulation. Results: Patients in physician-pharmacist collaborative clinics had significant improvements in medication compliance (p = 0.009), QoL (p = 0.036) and emergency visits (p = 0.003) over the 12-month. Pairwise comparison showed the medication compliance score in the intervention group had been significantly improved at 3rd month (p = 0.001), which is more rapidly than that in the control group at 9th month (p = 0.030). Factors influencing the implementation of physician-pharmacist collaborative clinics were driven by five themes: pharmaceutical service, team-base care, psychological support, acceptability of care and barriers to implementation. Conclusion: Integration of quantitative and qualitative findings showed the effectiveness of physician-pharmacist collaborative clinics in patient medication compliance and QoL in primary healthcare. The qualitative study uncovered barriers in insufficient clinical experience and understaffing of pharmacist. Therefore, the professional training of the primary pharmacist team should be improved in the future. Clinical Trial Registration: clinicaltrials.gov, identifier ChiCTR2000031839.
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Affiliation(s)
- Jie Xiao
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China
- Institute of Clinical Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Qing Wang
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China
- Institute of Clinical Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Shenglan Tan
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China
- Institute of Clinical Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Lei Chen
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China
- Institute of Clinical Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Bingjie Tang
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China
- Institute of Clinical Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Shuting Huang
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China
- Institute of Clinical Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Yangang Zhou
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China
- Institute of Clinical Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Ping Xu
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China
- Institute of Clinical Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China
- *Correspondence: Ping Xu,
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Vu A, Nicholas SB, Waterman AD, Madievsky R, Cheng F, Chon J, Fu JY, Mangione CM, Norris KC, Duru OK. "Positive Kidney Health": Implementation and design of a pharmacist-led intervention for patients at risk for development or progression of chronic kidney disease. J Am Pharm Assoc (2003) 2022; 63:681-689. [PMID: 36593152 DOI: 10.1016/j.japh.2022.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 11/06/2022] [Accepted: 11/14/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Patients with early chronic kidney disease (CKD) or underlying risk factors are often unaware of their kidney test results, common causes of CKD, and ways to lower risk of disease onset/progression. OBJECTIVE To test feasibility of a pharmacist-led intervention targeting patient education and risk factors in patients with early CKD and those at risk for CKD. PRACTICE DESCRIPTION Ambulatory care pharmacists in community-based primary care clinics delivered kidney health education, ordered labs, and recommended medication adjustments. PRACTICE INNOVATION We identified patients with a moderate rate of decline (≥2 mL/min/1.73 m2 per year) in estimated glomerular filtration (eGFR) at-risk for CKD or early stage CKD. An interactive workbook was designed to teach patients about kidney test results and self-management of risk factors including hypertension, type 2 diabetes, cigarette smoking, and chronic oral nonsteroidal anti-inflammatory drug use. EVALUATION METHODS Outcomes included visit uptake, completion of annual albuminuria screening, and initiation of guideline-directed medications for CKD. Patients were surveyed pre- and post-intervention for kidney health knowledge and perceptions regarding pharmacist-provided information. RESULTS Our sample of 20 participants had a mean eGFR of 59 mL/min/1.73 m2 and the mean eGFR decline was -4.6 mL/min/1.73 m2 per year. There were 47 visits during the pilot period from February 2021 to October 2021. Thirteen patients were missing albuminuria screening within 12 months; 2 of 9 patients with resulting labs had new microalbuminuria and were started on renoprotective medications. Patients had improved understanding of their kidney function test results and most did not consider the information scary or confusing. CONCLUSION Barriers to enrollment included fewer participants with multiple risk factors for CKD. The pharmacists were able to engage patients in learning the importance of monitoring and self-management of kidney health. A collaborative practice agreement may enhance a similar intervention that includes initiation of renoprotective medications.
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