The Role of Clinical Pharmacists in Patient-Centric Comprehensive Multiple Sclerosis Care

BACKGROUND

Individuals with multiple sclerosis (MS) may experience a variety of visible and invisible symptoms and, as they age, comorbidities related and unrelated to their MS. This can result in a complex medication regimen that includes disease-modifying therapies, symptom management drugs, and prescriptions for other comorbid disorders.

METHODS

We reviewed the existing literature to discover how to optimally integrate neurology clinical pharmacists into the MS care team and how clinical pharmacists can directly support both providers and patients through their expertise in pharmacology and medication management.

RESULTS

With approaches founded on a shared decision-making process alongside neurology providers, patients, and care partners, clinical pharmacists can help meet the complex challenges of MS care in a variety of ways. Especially within MS clinics, they are well positioned to enhance current neurology practices given their extensive training in comprehensive medication management and their ability to identify nuances in medication management to promote pharmacovigilance and patient-centered care.

CONCLUSIONS

Neurology clinical pharmacists bring multifaceted medication management and patient counseling and education skills to the MS care team and can support the shared decision-making process by serving as an accessible resource for patients and clinicians. By building trusted partnerships between neurology providers and clinical pharmacists, MS care teams can achieve effective and efficient patient care. Future research should compare clinical and patient-reported outcomes between patients receiving standard care and those receiving multidisciplinary, pharmacist-integrated care.

Patient-reported outcomes and pharmacist actions in patients with multiple sclerosis managed by health-system specialty pharmacies

PURPOSE

This study evaluated patient-reported outcomes (PROs) and pharmacist actions for patients on disease-modifying therapies (DMTs) for multiple sclerosis (MS) through health-system specialty pharmacies (HSSPs).

METHODS

A multisite, prospective cohort study of patients utilizing an HSSP for DMT fulfillment was performed. Primary outcomes were affirmative answers to PRO questions regarding impacted productivity, hospitalization, and relapse and pharmacist actions. Rates of pharmacist actions were reported as the number of person-years of treatment per action. Univariate and multivariate logistic regression were used to evaluate the association between each PRO and covariates, including the number of pharmacist actions performed, age, sex, insurance, site, and route of administration.

RESULTS

The 968 patients included had 10,562 fills and 6,946 PRO assessments. The most common affirmative PRO was impacted productivity (14.6%). Pharmacists performed 3,683 actions, most commonly general medication education (42.6%) and safety (33.3%). Rates of general medication education and nonfinancial coordination of care actions were similar across medication classes; other pharmacist actions varied by medication class. Insurance type was significantly associated with reporting impacted productivity; patients with Medicare and Medicaid were 2.2 and 3.1 times more likely to have reported impacted productivity, respectively (P < 0.001) than commercially insured patients. Patients who reported impacted productivity had more pharmacist actions (P < 0.001).

CONCLUSION

Patients on DMTs through an HSSP reported low rates of impacted productivity, relapse, and hospitalization due to MS, although patients with noncommercial insurance were more likely to have impacted productivity. Patients reporting impacted productivity and those taking certain DMTs may require more frequent pharmacist actions.

2022 ASHP Survey of Health-System Specialty Pharmacy Practice: Clinical Services

PURPOSE

Results of the first ASHP national survey of clinical services provided by health-system specialty pharmacies (HSSPs) are presented.

METHODS

A survey questionnaire was developed by 26 HSSP contacts after reviewing available literature on the role and services of HSSPs. After pilot and cognitive testing resulting in a final questionnaire of 119 questions, a convenience sample of 441 leaders in HSSPs was contacted using email and invited to participate in the survey.

RESULTS

The survey response rate was 29%. Almost half of respondents (48%) had offered pharmacy services for 7 years or more, and most (60%) dispensed more than 15,000 prescriptions annually. Respondents most commonly (42%) reported a specialist model wherein staff are dedicated to specific specialty disease states. Over half of respondents reported providing several medication access, pretreatment assessment, and initial counseling services to patients referred to them, regardless of whether the HSSP was used for medication fulfillment. All HSSP activities were noted to be documented in the electronic health record and visible to providers frequently or always. Almost all respondents noted that HSSP pharmacists have a role in specialty medication selection. Disease-specific outcomes were tracked in 95% of responding HSSPs, with 67% reporting that outcomes were used to drive patient monitoring. HSSPs were often involved in continuity of care services such as transitions of care (reported by 89% of respondents), referral to other health-system services (53%), and addressing social determinants of health (60%). Most respondents (80%) reported providing clinical education to specialty clinic staff, including medicine learners (62%). Though only 12% of respondents had dedicated outcomes research staff, many reported annually publishing (47%) or presenting (61%) outcomes research.

CONCLUSION

HSSPs are a clinical and educational resource for specialty clinics and have developed robust patient care services that encompass the patient journey from before specialty medication selection through treatment monitoring and optimization.

Adherence and persistence to self-administered disease-modifying therapies in patients with multiple sclerosis: A multisite analysis

BACKGROUND

Though there are several disease-modifying therapy (DMT) options for patients with multiple sclerosis (MS), treatment outcomes rely on patient adherence and persistence. Previous studies have demonstrated suboptimal adherence rates and high rates of early treatment discontinuation. Health-system specialty pharmacies (HSPPs) are a growing practice model that have demonstrated adherence and persistence benefits through single site evaluations. Research is needed across multiple HSSPs to understand and validate the outcomes of this practice model.

METHODS

A multisite prospective cohort study was performed including patients with at least three fills of a DMT between January 2020 and June 2021 at an HSSP. Patients were excluded due to pregnancy or death. Enrollment occurred for 6 months followed by 12 months of follow-up. Adherence was measured using pharmacy claims to calculate proportion of days covered (PDC) during the follow-up period. Time to non-persistence was calculated as the time from an index DMT fill to the first date of a gap of >60 days between medication exhaust and fulfillment dates. Adherence and persistence calculations were assessed at the therapeutic class level (any self-administered DMT dispensed by the HSSPs). The Kaplan-Meier method was used to present the probability of being persistent, and Cox proportional hazards regression analysis was used to estimate hazard ratios of factors associated with non-persistence, which included age, sex, study site, insurance type, and whether the patient switched medication as potential factors.

RESULTS

The most common self-administered DMTs filled among 968 patients were glatiramer acetate (32%), fingolimod (18%), and dimethyl fumarate (18%). Most patients (96%) did not switch DMT during the study period. The median PDC was 0.97 (interquartile range 0.90-0.99), which was similar across all sites. Patients who had at least one DMT switch were 76% less likely to have a higher PDC than those who did not have any switch after adjusting for other covariates (Odds ratio: 0.24, 95% confidence interval [CI]: 0.14-0.40, p<0.001). Most patients (86%) were persistent to DMT over the 12-month study period. Among those non-persistent, median time to non-persistence was 231 (IQR 177-301) days. Patients who switched medications were 2.4 times more likely to be non-persistent (95% CI: 1.3 - 4.5, p = 0.005). The most common reasons for non-persistence were discontinuation/medication held for an extended period (30%), often due to patient or prescriber decision (75%).

CONCLUSION

High rates of DMT adherence and persistence were seen among patients serviced by HSSPs, indicating potential benefits of this model for patients with MS. Switching DMTs was associated with lower adherence and persistence and may be an opportunity for added care coordination or resources to optimize therapy transitions.

Explaining the burden of psychosocial factors on the worsening symptoms of MS: a qualitative study of patients' experiences

BACKGROUND

This study was conducted with the aim of identifying the burden of psychosocial factors on the worsening symptoms of multiple sclerosis.

METHODS

This as conducted with a qualitative approach and conventional content analysis among patients with Multiple sclerosis in Mashhad. Data were collected through semi-structured interviews with patients with Multiple sclerosis. Twenty-one patients with Multiple sclerosis were selected through purposive sampling and snowball sampling. The data were analyzed using Graneheim and Lundman method. Guba and Lincoln's criteria were used for evaluating research transferability. The data collection and management was performed by using the MAXQADA 10 software.

RESULTS

In explanation of the psychosocial factors of patients with Multiple sclerosis, one category (psychosocial tensions) and three subcategories of stress (physical symptoms, emotional symptoms, and behavioral symptoms), agitation (family disorder, treatment-related concerns, and social relationship concerns), and stigmatization (social stigma and internalized stigma) were extracted.

CONCLUSION

The results of this study show that patients with Multiple sclerosis are faced with concerns such as stress, agitation, and fear of stigma, and need support and understanding from the family and community to overcome these concerns. Society must base its health policies on addressing the challenges faced by patients. Accordingly, the authors argue that health policies, and consequently, healthcare systems, need to address patients' ongoing challenges as a priority in caring for patients with Multiple sclerosis.

Health-system specialty pharmacy role and outcomes: A review of current literature

DISCLAIMER

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

PURPOSE

Specialty medications can have life-altering outcomes for patients with complex diseases. However, their benefit relies on appropriate treatment selection, patients' ability to afford and initiate treatment, and ongoing treatment optimization based on patient response to therapy. Mounting research demonstrates the benefits of the health-system specialty pharmacy (HSSP) in improving specialty medication access, affordability, and outcomes. The purpose of this rapid review is to describe the currently reported role and function of HSSP pharmacists and outcomes reported with use of the HSSP model, and to identify gaps in the literature where more information is needed to better understand the HSSP model and outcomes.

SUMMARY

Current literature describes the role of HSSP pharmacists in facilitating patient access, affordability, and initiation and maintenance of specialty medications. Though it is clear HSSP pharmacists are involved in treatment monitoring, often through utilizing the electronic health record, more information is needed to elucidate the frequency, method, and extent of monitoring. Despite several valuable continuity of care services reported to be provided by HSSPs, the breadth and degree of standardization of these services remains unclear. There is minimal literature describing HSSP education and research involvement. HSSPs have reported significant benefits of this patient care model, as demonstrated by higher adherence and persistence; better clinical outcomes; financial benefits to patients, payers and the health system; better quality of care; higher patient and provider satisfaction with services, and highly efficient specialty pharmacy services. More literature comparing clinical and diagnosis-related outcomes in HSSP versus non-HSSP patients is needed.

CONCLUSION

HSSPs provide comprehensive, patient-centered specialty medication management that result in improved care across the continuum of the specialty patient journey and act as a valuable resource for specialty clinics and patients beyond medication management. Future research should build on the current description of HSSP services, how services affect patient outcomes, and the impact HSSP network restrictions.

Evaluation of the impact of a clinical pharmacist on a specialty neurology clinic's adherence to recommended laboratory test monitoring

BACKGROUND: Pharmacists can have a significant effect on the specialty ambulatory care setting. Specialty medications are potentially high risk and may require frequent laboratory test monitoring to assess for therapy-associated adverse effects. Pharmacists may work under collaborative drug therapy management agreements that allow for the ordering and assessment of recommended laboratory tests in order to optimize safe and effective medication use. The impact of pharmacists on clinic adherence to recommended laboratory test monitoring has yet to be described in the literature. OBJECTIVE: To describe the impact of a specialty clinical pharmacist on neurology clinic adherence to manufacturer-recommended laboratory test monitoring. METHODS: This study was a retrospective chart review at a single academic medical center for the period between July 1, 2014, and April 30, 2020, comparing laboratory test monitoring adherence before (prepharmacist) and after (post-pharmacist) incorporation of a pharmacist into a neurology clinic. Patients were included if they lived in the Tri-County Area of Charleston, South Carolina, and received a prescription for dalfampridine, dimethyl fumarate, fingolimod, teriflunomide, or cannabidiol that was prescribed by a neurology clinic provider at the Medical University of South Carolina. Chart review was conducted to assess clinic adherence with manufacturer-recommended laboratory test monitoring. Laboratory test monitoring was considered adherent if obtained within 6 months before or on the date of prescription order. Descriptive statistics were calculated for all variables, and adherence rates were compared using chi-square or Fisher's exact tests. RESULTS: For dalfampridine, dimethyl fumarate, fingolimod, and teriflunomide, there were 123 patients and 78 patients in the pre- and post-pharmacist groups, respectively. There were 51 patients in the cannabidiol group. Clinic adherence to laboratory test monitoring improved in the post-pharmacist group for every monitoring point, with statistically significant improvement in "hepatic function tests every 6-9 months" (P = 0.005), "CBC every 6-9 months" (P = 0.01), and "VZV IgG titer at baseline" (P = 0.005) for patients taking fingolimod. CONCLUSIONS: Our study demonstrated improved adherence to manufacturer-recommended laboratory test monitoring after a specialty clinical pharmacist was incorporated into a multidisciplinary neurology clinic. DISCLOSURES: No funding supported this study. The authors have nothing to disclose.

Factors associated with fingolimod rebound: A single center real-life experience

Background It is still controversial whether the relapse experienced after discontinuation of fingolimod treatment is a rebound. Increasing cases of rebound have been reported in the literature. The rate of fingolimod rebound in patients after fingolimod cessation is reported between 5% and 52%. The present study aims to determine the rate of rebound after discontinuation of fingolimod treatment and the factors affecting the rebound. Methods This retrospective cohort study consists of adult MS patients who have been admitted to the Hacettepe University Hospital Neurology MS Center outpatient clinic between 2012 and 2020. Results During the study period, 642 patients received fingolimod and 23.1% discontinued the fingolimod treatment. Thirteen of 126 patients had a rebound (10.3%) after fingolimod discontinuation. The patients in the rebound group were significantly younger and washout period were significantly longer than those in the non-rebound group. After discontinuation of fingolimod treatment, the EDSS score of the rebound group was significantly higher than the non-rebound group, while Annualized Relapse Rates were similar. Conclusion Younger age, longer washout time, and previous treatment preferences may increase the occurrence probability of rebound. It is recommended that patients should be closely monitored after fingolimod discontinuation and appropriate disease-modifying therapy should be initiated as soon as possible.

Proportion of days covered as a measure of medication adherence

In an effort to expedite the publication of articles , AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

Drug Re-purposing Approach and Potential Therapeutic Strategies to Treat COVID-19

The current pandemic of COVID-19 caused by SARS-Cov-2 has posed a severe threat to the whole world with its highly infectious, progressive nature with up to 10% mortality rates. The severity of the situation faced by the whole world and the lack of efficient therapeutics to treat this viral disease have led the WHO to depend on the drug-repurposing approach to tackle this major global health problem. This review aims at highlighting the various synthetic approaches employed for the synthesis of these FDA approved drugs that have been presently used for COVID-19 treatment. Additionally, a brief overview of several therapeutic strategies is also presented. This review will encourage the scientific community across the globe to come up with better and efficient synthetic protocols and also novel chemical entities along with this core with more potent activity.

Comparison of provider satisfaction with specialty pharmacy services in integrated health-system and external practice models: A multisite survey

Purpose

The purpose of this study is to obtain insight into providers’ satisfaction with services offered by health-system integrated specialty pharmacies and to determine whether providers’ perceptions of services offered under an integrated model differ from perceptions of external specialty pharmacy services.

Methods

A multi-site, cross-sectional, online survey of specialty clinic healthcare providers at 10 academic health systems with integrated specialty pharmacies was conducted. The questionnaire was developed by members of the Vizient Specialty Pharmacy Outcomes and Benchmarking Workgroup and was pretested at 3 pilot sites prior to dissemination. Prescribers of specialty medications within each institution were identified and sent an email invitation to participate in the study that included a link to the anonymous questionnaire. Respondents were asked to rate their agreement with 10 statements regarding quality of services of integrated and external specialty pharmacies on a 5-point scale (1 = strongly disagree, 5 = strongly agree). An analysis to determine differences in providers’ overall satisfaction with the integrated and external specialty pharmacy practice models, as well as differences in satisfaction scores for each of the 10 statements, was performed using paired-samples t tests.

Results

The mean (SD) score for overall satisfaction with integrated specialty pharmacies was significantly higher than the score for satisfaction with external specialty pharmacies: 4.72 (0.58) vs 2.97 (1.20); 95% confidence interval, 1.64-1.87; P &lt; 0.001. Provider ratings of the integrated specialty pharmacy model were also higher for all 10 items evaluating the quality of services (P &lt; 0.05 for all comparisons).

Conclusion

The study results confirm that the health-system integrated specialty pharmacy practice model promotes high rates of provider satisfaction with services and perceived benefits.

Multidisciplinary practice advancement: Role of a clinical pharmacy specialist in a pediatric specialty clinic

Purpose

To describe clinical pharmacy specialists’ role in improving the use of specialty medications within a pediatric outpatient setting.

Summary

The outpatient pediatric specialty clinic (PSC) at the University of Iowa added a clinical pharmacy specialist to multidisciplinary teams within the PSC to focus on patient education, providing clinical recommendations, coordinating insurance approval, addressing barriers to adherence, and performing follow-up monitoring. Supplemental activities include coordinating between the electronic health record–integrated on-site specialty pharmacy and the PSC, assisting with quality improvement projects, developing policy revisions, negotiating access to specialty products, and answering medication information questions. Benefits in workflow efficiency, documentation, and revenue generation resulting from implementation of the pharmacist within the PSC have been identified by the clinic and the specialty pharmacy. The specialty pharmacy identified an increase in the rate of specialty prescription capture from 14% to 50%, leading to an increase in revenue for the health system. Within 12 months of the addition of the pharmacist to the team, an improvement in the rate of 13-valent pneumococcal conjugate vaccine administration to pediatric patients of 25.7 percentage points, medication adherence of &gt;90%, and a 75% relative increase in appropriate hydroxychloroquine dosing were recognized. Due to the pharmacist’s impact on the PSC, a full-time pharmacist was added to the pediatric team to cover additional clinics, and 2 benefits investigation technicians were hired and funded by the PSC.

Conclusion

An interdisciplinary team with an integrated pharmacist has facilitated sustainable improvements in medication access and adherence and clinical and quality measures, benefiting patients, the pediatric clinic, the specialty pharmacy, and the hospital organization.

Assessing Pharmacists' Preferences towards Efficacy Attributes of Disease-Modifying Therapies in Relapsing-Remitting Multiple Sclerosis

Introduction: Hospital pharmacists are increasingly playing a critical role in the care of patients with multiple sclerosis (MS). However, little is known about their preferences and perspectives towards different attributes of disease-modifying therapies (DMTs). The objective of this research was to assess pharmacists´ preferences for DMT efficacy attributes. Methods: A multicenter, non-interventional, cross-sectional, web-based study was conducted. Preventing relapses, delaying disease progression, controlling radiological activity, and preserving health-related quality of life (HRQoL) and cognition were the attributes selected based on a literature review and a focus group with six hospital pharmacists. Conjoint analysis was used to determine preferences in eight hypothetical treatment scenarios, combining different levels of each attribute and ranking them from most to least preferred. Results: Sixty-five hospital pharmacists completed the study (mean age: 43.5 ± 7.8 years, 63.1% female, mean years of professional experience: 16.1 ± 7.4 years). Participants placed the greatest preference on delaying disease progression (35.7%) and preserving HRQoL (21.6%) and cognition (21.6%). Importance was consistent in all groups of pharmacists stratified according to demographic characteristics, experience, research background, and volume of patients seen per year. Conclusions: Understanding which treatment characteristics are meaningful to hospital pharmacists may help to enhance their synergistic role in the multidisciplinary management of patients with MS.

Promoting transitions of care, safety, and medication adherence for patients taking fingolimod in community pharmacies

PURPOSE

The development and dissemination of a specialty pharmacy service to optimize fingolimod therapy management are described.

SUMMARY

Fingolimod was the first oral therapy developed to counter relapsing-remitting multiple sclerosis. Pharmacovigilance measures and individualized support are strongly recommended due to associated safety concerns. The Fingolimod Patient Support Program (F-PSP) was developed and disseminated within a community pharmacy network. The F-PSP aims to ensure responsible use of fingolimod and patient empowerment by promoting medication adherence and patient safety through a person-centered and integrated care approach. It complements basic pharmacy services through 2 interventions: medication adherence support and pharmacovigilance tailored to fingolimod. The adherence intervention combines motivational interviewing with longitudinal electronic medication adherence monitoring. The pharmacovigilance component consists of informing patients of fingolimod recommendations, reminding patients of recommended medical tests, and tracking and monitoring symptoms, especially those of potential serious adverse fingolimod reactions. A secure Web platform guides the pharmacist in conducting interviews and enables collection of patient-reported outcome data. A transition care pharmacist proposes program participation to all patients initiated on fingolimod, performs enrollment, and coordinates transfers to patient-designated community pharmacies for ongoing care.

CONCLUSION

The F-PSP enables support of individual patients, and also provides real-world data, helping to bridge the gap between practice and research. The F-PSP is intended to be a generic model of a specialty pharmacy service that is transferable to any other healthcare context, specialty drug or disease.

Factors associated with therapeutic inertia among pharmacists caring for people with multiple sclerosis

INTRODUCTION

Pharmacists play a critical role on therapeutic decisions in multiple sclerosis (MS) care. Therapeutic inertia (TI) is defined as the lack of treatment initiation or escalation when there was evidence of clinical and radiological disease activity. The aim of this study was to assess factors associated with TI among pharmacists involved in MS care.

METHODS

A multicenter, non-interventional, cross-sectional study involving hospital pharmacists in Spain was conducted. Participants answered questions regarding their standard practice, risk preferences, and management of nine simulated MS case-scenarios. We created a score defined as the number of case-scenarios that fit the TI criteria over the total number of presented cases (score range from 0-6). Similarly, an optimal treatment score (OTS) was created to determine the degree of appropriate pharmacological decisions (ranging from 0-lowest to 9-highest). Candidate predictors of TI included demographic data, practice setting, years of practice, MS expertise, number of MS patients managed at hospital/year, participation in MS clinical trials, and participants' risk preferences.

RESULTS

Overall, 65 pharmacists initiated and completed the study (response rate: 45.5%). The mean age was 43.5 ± 7.8 years and 67.1% were female. Forty-two (64.6%) participants had specialization in MS management. Overall, the mean TI score was 3.4 ± 1.1. Of 390 individual responses, 224 (57.4%) met the TI criteria. All participants failed to recommend treatment escalation in at least one of the six case-scenarios. The mean OTS was 4.1 ± 1.4. Of 585 individual responses, 264 (45.1%) met the optimal choice criteria. Only 40% of participants (23/65) made five or more optimal treatment choices. Lower experience in dispensing MS drugs and lack of specialization in MS were the most common factors associated with TI and optimal management. The multivariable analysis revealed that more years of experience (p = 0.03), being a co-author of a peer-reviewed publication (p = 0.03), and specialization in MS (p = 0.017) were associated with lower TI scores (adjusted R² = 0.23).

CONCLUSION

Therapeutic inertia was observed in all pharmacist participants, affecting over fifty percent of MS treatment choices. Continuing education and specialization in MS may facilitate therapeutic decisions in MS care.

Advancing Patient Care Through Specialty Pharmacy Services in an Academic Health System

BACKGROUND

With the rapid growth of specialty pharmacies, including those within academic health systems, pharmacists have the opportunity to improve patient care through the management of specialty medications. Specialty pharmacists within academic health systems are uniquely positioned to overcome restrictions to medication access, financial constraints, and provider burdens that often lead to obstacles for patients to start and maintain necessary treatments. The Vanderbilt Specialty Pharmacy (VSP) model at Vanderbilt University Medical Center (VUMC) provides an example of a patient-centered, collaborative care prototype that places pharmacists directly into specialty clinics to assist with comprehensive management of patients on specialty medications.

PROGRAM DESCRIPTION

VSP integrates specialty pharmacy services within existing specialty clinics based on the needs of each individual clinic. Each clinic is staffed with at least 1 clinical pharmacist and 1 pharmacy technician. The pharmacist is integrally involved in medication selection, initiation, and monitoring. The specialty pharmacy team ensures appropriate medication access and cost, provides extensive medication education, ensures patients are adherent to treatment, and coordinates care between patients and providers using the electronic medical record.

OBSERVATIONS

Integration of pharmacists within specialty clinics at VUMC benefits providers, the health system, and patient care. This model has demonstrated decreased provider and clinic burden, decreased time to medication approval and initiation, excellent patient and provider satisfaction, substantial patient cost savings, optimal medication adherence, and overall improved continuity of care for patients on specialty medications. Since its inception in 2011, VSP has integrated 24 clinical pharmacists and 17 pharmacy technicians into 20 specialty clinics, with continued quarterly growth.

IMPLICATIONS

The VSP model advances the role of pharmacists in managing patients on specialty medications in collaboration with providers. The integrated collaborative approach as presented by VSP represents a best practices model for those establishing and advancing specialty pharmacy services within academic health systems.

DISCLOSURES

No outside funding supported this study. The authors have nothing to disclose. Study concept and design were principally contributed by Bagwell and Newman, along with the other authors. Lee took the lead in data collection, along with Carver, Bagwell, Kelley, and Newman. Data interpretation was performed by Carver, Kelley, Lee, and Bagwell, with assistance from Newman. The manuscript was written by Bagwell, Carver, Kelley, and Lee and revised primarily by Bagwell, along with the other authors.

Implementation of a New Clinic-Based, Pharmacist-Managed PCSK9 Inhibitor Consultation Service

BACKGROUND

The proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors alirocumab and evolocumab were approved by the FDA in 2015. In anticipation of provider interest and a potential increase in referrals to the on-site specialty pharmacy, we created a pharmacist-managed consultation service.

PROGRAM DESCRIPTION

The development of a clinic-based pharmacist-managed consultation service for the management of the PCSK9 inhibitor agents alirocumab and evolocumab is described. Key implementation steps included (a) creation of a pharmacy team and collaboration with cardiology; (b) completion of a needs assessment; (c) service creation; (d) collaboration with the on-site specialty pharmacy; (e) development of an electronic consult order and consult pool; (f) personnel training; and (g) service approval and marketing. The service development occurred over 9 months (July 2015-April 2016) and was implemented hospital-wide in May 2016.

OBSERVATIONS

The University of Illinois Hospital and Health Sciences System PCSK9 inhibitor consultation service successfully integrated the benefits of a clinical review process, information technology capabilities of an electronic medical record system, and collaboration with the on-site specialty pharmacy to provide a comprehensive service that aimed to facilitate appropriate medication management from prescribing to patient administration and provide monitoring for this class of specialty medications.

IMPLICATIONS/RECOMMENDATIONS

The PCSK9 pharmacist-managed consultation service provides a method for complex therapies to be managed comprehensively through the collaboration of ambulatory care clinics and outpatient specialty pharmacies.

DISCLOSURES

No outside funding supported this study. Groo reports speaker bureau fees from Pfizer and Bristol-Myers Squibb. The other authors have nothing to disclose. All the authors contributed to study concept and design. Atande took the lead in data collection, and data interpretation was performed by Groo and Atanda. The manuscript was written by Atanda and revised by all the authors.

Evolving concepts in the treatment of relapsing multiple sclerosis

In the past 20 years the treatment scenario of multiple sclerosis has radically changed. The increasing availability of effective disease-modifying therapies has shifted the aim of therapeutic interventions from a reduction in relapses and disability accrual, to the absence of any sign of clinical or MRI activity. The choice for therapy is increasingly complex and should be driven by an appropriate knowledge of the mechanisms of action of the different drugs and of their risk-benefit profile. Because the relapsing phase of the disease is characterised by inflammation, treatment should be started as early as possible and aim to re-establish the normal complex interactions in the immune system. Before starting a treatment, neurologists should carefully consider the state of the disease, its prognostic factors and comorbidities, the patient's response to previous treatments, and whether the patient is likely to accept treatment-related risks in order to maximise benefits and minimise risks. Early detection of suboptimum responders, thanks to accurate clinical monitoring, will allow clinicians to redesign treatment strategies where necessary.

Epilepsy during pregnancy: focus on management strategies

In the US, more than one million women with epilepsy are of childbearing age and have over 20,000 babies each year. Patients with epilepsy who become pregnant are at risk of complications, including changes in seizure frequency, maternal morbidity and mortality, and congenital anomalies due to antiepileptic drug exposure. Appropriate management of epilepsy during pregnancy may involve frequent monitoring of antiepileptic drug serum concentrations, potential preconception switching of antiepileptic medications, making dose adjustments, minimizing peak drug concentration with more frequent dosing, and avoiding potentially teratogenic medications. Ideally, preconception planning will be done to minimize risks to both the mother and fetus during pregnancy. It is important to recognize benefits and risks of current and emerging therapies, especially with revised pregnancy labeling in prescription drug product information. This review will outline risks for epilepsy during pregnancy, review various recommendations from leading organizations, and provide an evidence-based approach for managing patients with epilepsy before, during, and after pregnancy.