Assessing pharmacogenomic literacy in China through validation of the Chinese version of the Minnesota Assessment of Pharmacogenomic Literacy

Pharmacogenomics (PGx) implementation into clinical care is rapidly increasing in China. However, the extent to which the public understands PGx testing and important knowledge domains requiring patient education or counseling remains unclear. To address this, we created and validated the Chinese version of the Minnesota Assessment of Pharmacogenomic Literacy (MAPL-CTM ). The MAPL-C was developed by translating the English MAPL to Chinese following cross-cultural translation guidelines. An online survey validated the MAPL-C and assessed Chinese individuals' PGx literacy. Validation analyses were performed and associations of PGx literacy with participants' characteristics were quantified. Of 959 high-quality responses, the majority of respondents were Han Chinese (96.3%), men (54.5%), aged 18-29 years (70.9%), residing in China (97.3%), and had received college or higher education (95.0%). Out of 15 starting items developed to query specific predefined knowledge domains, two uninformative items were excluded, resulting in a 13-item MAPL-C. Chinese participants' MAPL-C performance was best explained by a three-factor model, encompassing PGx concepts and function, testing limitations, and privacy. Higher MAPL-C performance was associated with younger age, higher education, and previous genetic testing experience. Correct response rates for questions related to testing limitations were lower than those in other domains. The creation and validation of the MAPL-C fills a gap in determining PGx knowledge among Chinese speakers, quantifying PGx literacy within a Chinese cohort, and identifying response patterns and knowledge gaps. The MAPL-C can be useful in clinical practice to guide patient counseling, assess PGx education interventions, and quantify PGx knowledge in relation to outcomes in research studies involving Chinese participants.

Development and validation of a tool to assess the readiness of a clinical teaching site for interprofessional education (InSITE)

Interprofessional education within clinical teaching sites is a key part of training for pre-professional students. However, the necessary characteristics of these interprofessional clinical teaching sites is unclear. We developed a tool, the Interprofessional Education Site Readiness, or InSITE, tool, for individuals at a site to use as a self-assessment of the site's current readiness for providing interprofessional education. The tool progressed through six stages of development, collecting evidence for validity and reliability, resulting in a final tool with 23 questions distributed across five domains. Data from 94 respondents from a variety of national sites were used for the item analysis showing acceptable item-to-total correlations. Internal reliability testing gave a Cronbach's coefficient alpha of more than 0.70 for each group level comparison. Known groups validity testing provides strong evidence for its responsiveness in detecting differences in sites where IPE is implemented. The results of the testing lead us to conclude that the InSITE tool has acceptable psychometric properties. Additionally, we discovered that the process in which the InSITE tool was used demonstrated that it can facilitate learning in practice for the health professionals and can help make implicit, informal workplace learning and the hidden curriculum explicit.

Medical Residents' Informal Learning from Pharmacists in the Clinical Workplace

Workplace-based interactions between residents and pharmacists, though relatively underexplored, might contribute substantially to learning. This international study sought to investigate the affordances residents use for informal learning about medications, their interactions with pharmacists and patterns of resident-pharmacist engagement, as well as residents' perceived impact of these interactions on their learning. Contextual differences between US and Dutch residency training and electronic health record (EHR) may impact informal learning about medications. We conducted a cross-sectional, online, 25-item survey study, including closed-format and open-response questions among current resident physicians (post-graduate years 1-6, from a variety of residency programs n = 803) from the University of California San Francisco, the University of Minnesota, and the University Medical Center Utrecht. Responses from 173 residents in both countries revealed that these physician trainees were afforded opportunities to engage in a wide variety of pharmacotherapy-related activities but engaged differently with social and environmental resources for support. Residents from the United States (US) utilized pharmacists and Up-To-Date, whereas Dutch residents preferentially utilized the online Dutch medication information site and EHR-embedded medication resources. US residents interacted with pharmacists significantly more frequently than Dutch residents. Pharmacists provided residents with a wide range of useful information, much of which is integrated into the medication resources in the Dutch EHR-based decision-support system. While US residents reported overwhelmingly that informal interactions with pharmacists contribute to their learning about medications, Dutch residents' responses did not confirm this. Intentionally designing residents' training to include opportunities for interactions with pharmacists could potentially positively impact residents' informal workplace learning.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40670-023-01784-1.

Beginning Early: Reflective Practice Development in a Pre-health Course on Health Literacy and Health Disparities

Background: Learning reflective practices and understanding the complexity of health literacy and health disparities need to start early in health professions training. The primary objective of this inquiry was to evaluate the feasibility and effectiveness of using reflection categorization for assessing learner progression on reflective practice development. The secondary objective was to evaluate student reflection as a strategy for introducing and advancing pre-professional learners' understanding of health literacy and health disparities. Case Description: Within an online undergraduate health literacy course, two written reflection assignments were coded using Kember’s four categories: habitual action, understanding, reflection, and critical reflection. Students received feedback based on this reflection categorization to promote development of reflective practices. However, reflections were not graded using the reflection categorization. Case Themes: Most (78%) students were at the level of understanding for the first reflection. For the second reflection, 29% of students were at the reflection level, demonstrating health literacy application and describing the important contributing role of personal context to health outcomes. Sixteen (33%) students progressed in their level of reflection. Within the reflections, students discussed knowledge gained and plans for future application. Conclusion: Using a structured reflection activity allowed pre-health students to begin developing reflection practices. Through reflection, students were able to describe and apply health literacy and health disparities knowledge.

A Scoping Review of Attitudes and Experiences with Pharmacogenomic Testing among Patients and the General Public: Implications for Patient Counseling

The use of pharmacogenomic (PGx) tests is increasing, but there are not standard approaches to counseling patients on their implications or results. To inform approaches for patient counseling, we conducted a scoping review of published literature on patient experiences with PGx testing and performed a thematic analysis of qualitative and quantitative reports. A structured scoping review was conducted using Joanna Briggs Institute guidance. The search identified 37 articles (involving n = 6252 participants) published between 2010 and 2021 from a diverse range of populations and using a variety of study methodologies. Thematic analysis identified five themes (reasons for testing/perceived benefit, understanding of results, psychological response, impact of testing on patient/provider relationship, concerns about testing/perceived harm) and 22 subthemes. These results provide valuable context and potential areas of focus during patient counseling on PGx. Many of the knowledge gaps, misunderstandings, and concerns that participants identified could be mitigated by pre- and post-test counseling. More research is needed on patients’ PGx literacy needs, along with the development of a standardized, open-source patient education curriculum and the development of validated PGx literacy assessment tools.

Addressing practical challenges with entrustable professional activities in ambulatory care experiential education

BACKGROUND AND PURPOSE

Entrustable professional activities (EPAs) have been adopted and endorsed by the American Association of Colleges of Pharmacy as an assessment strategy. Application of EPAs in ambulatory care advanced pharmacy practice experiences (APPEs) has demonstrated potential internal grading consistency challenges and warrants further guidance.

EDUCATIONAL ACTIVITY AND SETTING

Within a required ambulatory care APPE, a rubric was developed using purposeful and convenience sampling of preceptors, faculty, and students to concretely delineate expected EPA level progression from week one to week four based on setting specific activities.

FINDINGS

The rubric was perceived to be accurate and useful as a tool for improving expectations of progression in the respective roles on ambulatory care APPEs.

SUMMARY

Specifying performance of common clinical activities by weekly EPA level progression within an ambulatory care APPE was perceived to address some of the challenges in APPE grading consistency. Research for determining appropriate progression within an APPE and progression context within graduate and post-graduate training is needed. As more pharmacy training programs implement EPAs, collaboration in applying core EPAs into experiential education will be needed. This example of a setting specific progression rubric may serve as a useful tool for preceptors and students during their APPEs.

Interprofessional Education Within a Pilot HIV-Care Elective Course

Objective. To create an IPE course that improved knowledge related to HIV history, prevention, and therapy, in health professions students and improved their interest and confidence in becoming interprofessional collaborative clinicians, specifically involved in the care of people living with HIV. Methods. A motivational design framework was used to create an interprofessional course that incorporated whole-task complex scenarios, team-based application, and experiential components. Multiple sources of quantitative and qualitative data, including the AIDS Education and Training Center evaluation tool and Interprofessional Collaborative Competency Attainment Scale instrument, as well as assignments and course evaluations, were collected and analyzed. Results. Fifteen students from medicine, nursing, and pharmacy participated in 2017, and 21 students from medicine, nursing, pharmacy, and social work participated in 2018. In both offerings, students rated the course experience positively and self-reported increases in confidence related to interprofessional competencies. Ninety-three percent and 68% of the students in 2017 and 2018, respectively, stated they planned to be involved in HIV care to some degree in the future. Students demonstrated high levels of knowledge of the AIDS Training & Education Center National HIV Curriculum at the end of the 2018 course offering. Conclusion. This educational course design provided an effective interprofessional learning experience and establishes a sustainable interprofessional format for teaching health professions students about HIV.

Closing the Classroom Theory to Practice Gap by Simulating a Psychiatric Pharmacy Practice Experience

Objective. To examine the feasibility and effectiveness of combining whole-task and guided reflection educational design principles with cloud-based learning technologies to simulate the clinical psychiatric advanced pharmacy practice experience (APPE) in the classroom to begin to close the theory to practice gap. Methods. Components of the typical student experience while completing an APPE were integrated into the course experience, ie, patient case work-ups, facilitated sessions with a preceptor, personal statement of goals and progress with feedback, and intentional interaction with peer-learners. Multiple sources of quantitative and qualitative data were collected and analyzed. Results. Twelve third-year pharmacy students from two campuses participated in and successfully completed this one-credit elective advanced psychiatric pharmacotherapy course. Eleven board-certified psychiatric pharmacists (BCPP) served as visiting experts, some participating for multiple weeks, and provided preceptor-like feedback to the case presentations in spring 2017. All BCPP pharmacists plus an additional geriatric pharmacist specialist participated in the course in spring 2018. Results of the quantitative and qualitative analyses demonstrated that students progressed in their readiness for APPEs and gained additional psychiatric pharmacy knowledge and evidence-based medicine decision making skills. Conclusion. Pharmacy programs are challenged to find additional ways to improve student readiness for APPEs and expand psychiatric learning opportunities to meet the increasing mental health needs across clinical settings. This example provides a feasible and effective strategy to do both without the requirement to create extensive new learning materials or add significant faculty workload.

Pharmacy Student Perceptions of the Entrustable Professional Activities

Objective. To determine pharmacy students' perceptions and self-reported preparedness to perform the 15 core entrustable professional activities (EPA) established by the American Association of Colleges of Pharmacy for new pharmacy graduates. Methods. A random sample of Doctor of Pharmacy (PharmD) students from all four professional years at four universities were asked to indicate whether each of the 15 EPA statements was relevant to the practice of pharmacy and whether pharmacists were expected to perform the activity in multiple practice settings. Participants rated their self-perceived level of entrustability for each activity and indicated which three EPAs they felt most and least prepared to perform. Results. Four hundred twenty-three usable responses were received. The majority (≥85%) of students rated all of the EPA statements as relevant and ≥67% indicated that pharmacists were expected to perform them in multiple practice settings with a high percentage of agreement. Students' perceived need for supervision decreased from the P1 to P4 years. These data suggest that students' confidence to perform some activities grew as they gained experience and knowledge. However, in some cases, the self-perceived need for supervision regressed as students better understood the complexity of the activity. The EPA statements students felt most and least prepared to perform varied by year in the program. Conclusion. The core EPA statements were consistently rated by pharmacy students as relevant to pharmacy practice and as an expectation in multiple settings. Students perceived that they require less supervision when performing EPA activities as they progressed through the curriculum.

Validation of the entrustable professional activities for new pharmacy graduates

PURPOSE

The face validity of the core entrustable professional activities (EPAs) for new pharmacy graduates published by the American Association of Colleges of Pharmacy (AACP) in 2017 was evaluated.

METHODS

A 28-item questionnaire was sent to experienced pharmacy practitioners affiliated with 4 schools of pharmacy. In addition to demographic information about education, training, credentials, and practice setting, participants were asked whether each EPA statement was pertinent to pharmacy practice and an expected activity that all pharmacists should be able to perform. Questions regarding the secondary attributes of the EPA statements examined whether each activity is observable, is measurable, is transferable to multiple practice settings, and integrates multiple competencies.

RESULTS

The questionnaire was distributed to 137 eligible participants, and 71 usable survey responses were received. Participants consistently agreed (≥75% agreement) that the 15 EPA statements for new pharmacy graduates describe activities that are pertinent to pharmacy practice and that pharmacists are expected to perform. A consistent level of agreement was observed regardless of the preceptor's employment with a college or school, board certification status, or completion of postgraduate training, and no statistical differences in level of agreement were found based on these attributes. There was consistent agreement (≥60%) across geographic regions. No statistical differences in agreement were found between acute care practitioners and ambulatory care practitioners.

CONCLUSION

A survey suggested that the core EPAs developed and vetted by AACP have face validity and are believed by experienced pharmacy preceptor-practitioners to be pertinent to pharmacy practice and to describe activities that all pharmacists should be able to competently perform.

Preceptor and resident perceptions of entrustable professional activities for postgraduate pharmacy training

BACKGROUND

Following the development and implementation of entrustable professional activities (EPAs) as a collective graduation standard for pharmacy students, the University of Minnesota's multi-site post-graduate year one pharmacy residency program made a similar transition.

EDUCATIONAL ACTIVITY AND SETTING

An electronic survey was distributed to program preceptors and residents to describe the perceptions of using EPAs to assess performance.

FINDINGS

Residents (66.7%) and preceptors (78.3%) found the EPA framework to be more helpful than the traditional progression ratings model, but both groups also described EPAs as less beneficial for some objectives. Sixteen (69.6%) preceptors felt the residency graduation standard for attainment should be an entrustment level 4 or 5. Preceptor's found the EPA scale to be more descriptive, more objective, and easier to understand; however, it did not always apply to all skills and was more challenging to provide residents information regarding what they needed to improve upon. Residents commented that the EPA scale was more descriptive, had better clarity, and gave them a better idea of where their progression was at on a continuum. Residents also commented that regardless of the rating scale, specific, day-to-day feedback is more helpful.

SUMMARY

Residents and preceptors perceive the EPA framework to be more helpful than traditional rating scales when evaluating learning objectives. Preceptors were less certain of what the EPAs entrustment level should be to consider a learning objective or skill achieved for residency. Both found some learning objectives to be more challenging for EPA use.

Personalized Learning in an Online Drugs and US Health Care System Controversies Course

Objective. To examine if personalized learning objectives influenced student engagement and if achievement of objectives could be measured from course assignments. Methods. Learners created personalized learning objectives that correlated with their own goals within the context of the course. Using a mixed-methods analysis approach, the influence of these objectives on engagement and evidence of achievement of objectives were examined. Results. Students reported a positive influence of personalized learning objectives on engagement. Additionally, measurement of student progression or achievement of objectives was possible from analysis of the course assignments. Conclusion. Personalized learning is an important educational design for future pharmacists and health care professionals. Creating personalized learning objectives that build on centralized course objectives and connect to a broader context is one way to achieve the goal of an engaged and expanded learning experience.

Report of the 2016-17 Academic Affairs Standing Committee: Entrustable Professional Activities Implementation Roadmap

The purpose of this report is to: 1) Identify linkages across the EPA statements, Center for the Advancement of Pharmacy Education 2013 Educational Outcomes (CAPE 2013) and the Joint Commission of Pharmacy Practitioners' Pharmacist Patient Care Process (PPCP); 2) Provide ways EPA statements can be used to communicate core skills that are part of the entry-level pharmacist identity; 3) Suggest a potential roadmap for AACP members on how to implement EPA statements.

The impact of proctored online exams on the educational experience

PURPOSE

This study explored new ways to maintain academic integrity for large enrollment, completely online courses. We examined the use of ProctorU as our proctoring strategy with the objectives to identify any implementation challenges and understand the impact of using an online proctor on the student experience.

METHODS

In fall 2013, students were surveyed after each exam. Based on these preliminary findings, ProctorU-related questions were included in the course evaluation administered in spring 2014. A mixed-methods analysis plan was used to examine the results, including quantitative analysis and qualitative analysis of open-ended survey questions.

RESULTS

In the fall 2013 surveys, 88.95% of students reported being satisfied with their experience using ProctorU. Of those who were unsatisfied, following three emerging themes were identified: took too long to setup, technical difficulties, and personnel issues with proctors. In the spring 2014 course evaluation data, the majority of students rated the experience "good" (57.53%), but a large number of those same students also commented on issues they encountered. Over half of the students indicated that the use of ProctorU would influence their future decision to take another online course, either negatively or positively.

CONCLUSIONS

The question of how to maintain academic integrity with online courses is still an ongoing question, but this project demonstrates that online proctoring does influence the educational experience in ways that must be considered when determining the risk and benefit balance of proctored and unproctored assessments.

Entrustable Professional Activities for Pharmacy Practice

The profession of pharmacy is facing a shifting health system context that holds both opportunity and risk. If the profession of pharmacy is to advance, pharmacists must be recognized as a consistent member of the health care team in all clinical settings, contributing at the fullest extent of licensure and education. One part of achieving this broad goal is to implement a new way of defining and assessing pharmacy practice skills, such as entrustable professional activities (EPA). Assessment of professional tasks and practice activities with EPAs has been successfully implemented in medical education for assessing trainee preparation for practice. This EPA model is being applied to pharmacy education to develop an assessment framework across the advanced pharmacy practice experience (APPE) curriculum. The APPE course directors, practice faculty members, and the Office of Experiential Education collaboratively defined a set of universal EPAs critical for pharmacists in any practice setting and would be assessed in all practice experience types.

An interprofessional diabetes experience to improve pharmacy and nursing students' competency in collaborative practice

OBJECTIVE

To improve pharmacy and nursing students' competency in collaborative practice by having them participate in an interprofessional diabetes experience involving social networking.

DESIGN

An existing elective course on diabetes management was modified to include interprofessional content based on Interprofessional Education Collaborative (IPEC) competency domains. Web-based collaborative tools (social networking and video chat) were used to allow nursing and pharmacy students located on 2 different campuses to apply diabetes management content as an interprofessional team.

ASSESSMENT

Mixed-method analyses demonstrated an increase in students' knowledge of the roles and responsibilities of the other profession and developed an understanding of interprofessional communication strategies and their central role in effective teamwork.

CONCLUSION

Interprofessional content and activities can be effectively integrated into an existing course and offered successfully to students from other professional programs and on remote campuses.

The use of social networking to improve the quality of interprofessional education

OBJECTIVE

To evaluate the feasibility and effectiveness of using an online social networking platform for interprofessional education.

DESIGN

Three groups of 6 students were formed with 1 student in each group from medicine, nursing, dentistry, pharmacy, veterinary medicine, and public health. Each group followed a different collaborative educational model with a unique pedagogical structure. Students in all groups interacted via an online social networking platform for a minimum of 15 weeks and met in person once at the end of the 15-week experience for a focus group session. The students were tasked with developing a collaborative recommendation for using social networking in interprofessional education programs.

ASSESSMENT

Most of the students who reported in a post-experience survey that their expectations were not met were in the minimally structured group. Almost all students in the facilitated and highly structured groups indicated that this experience positively impacted their knowledge of other health professions. Most students stated that interacting within a social networking space for 15 weeks with other members of the university's health professions programs was a positive and effective interprofessional education experience.

CONCLUSION

Social networking is feasible and can be used effectively within an overall strategy for interprofessional education, but design and placement within a core content course is critical to success.

Peer-led team learning in an online course on controversial medication issues and the US healthcare system

OBJECTIVE

To implement peer-led team learning in an online course on controversial issues surrounding medications and the US healthcare system.

DESIGN

The course was delivered completely online using a learning management system. Students participated in weekly small-group discussions in online forums, completed 3 reflective writing assignments, and collaborated on a peer-reviewed grant proposal project.

ASSESSMENT

In a post-course survey, students reported that the course was challenging but meaningful. Final projects and peer-reviewed assignments demonstrated that primary learning goals for the course were achieved and students were empowered to engage in the healthcare debate.

CONCLUSIONS

A peer-led team-learning is an effective strategy for an online course offered to a wide variety of student learners. By shifting some of the learning and grading responsibility to students, the instructor workload for the course was rendered more manageable.

Case-based assessment in an online nursing pharmacotherapy course

OBJECTIVE

To implement and evaluate the effectiveness of case-based assessments in an online pharmacotherapy course for nursing students.

DESIGN

Four case-based examinations developed in parallel for the midterm and final examinations and designed to address potential barriers to maintaining academic integrity were compared.

ASSESSMENT

The use of online, case-based assessments was successful in providing 4 parallel examinations that assessed case-based decision making while maintaining academic integrity and minimizing instructor grading burden.

CONCLUSIONS

Using an online, case-based assessment strategy is effective and feasible for evaluating the clinical application knowledge of nursing students enrolled in a pharmacotherapy course.

Student-generated questions to assess learning in an online orientation to pharmacy course

OBJECTIVE

To develop a formative assessment strategy for use in an online pharmacy orientation course that fosters student engagement with the course content and facilitates a manageable grading workload for the instructor.

DESIGN

A formative assessment strategy involving student-generated, multiple-choice questions was developed for use in a high-enrollment, online course.

ASSESSMENT

Three primary outcomes were assessed: success of the assessment in effectively engaging students with the content, interrater reliability of the grading rubric, and instructor perception of grading workload. The project also evaluated whether this metacognitive strategy transferred to other aspects of the students' academic lives. The instructor perception was that the grading workload was manageable.

CONCLUSION

Using student-generated multiple-choice questions is an effective approach to assessment in an online course introducing students to and informing them about the profession of pharmacy.

Pharmacy students' views of managed care pharmacy and PBMS: should there be more exposure to managed care in the pharmacy curriculum?

BACKGROUND

New accreditation standards implemented in 2007 have required schools of pharmacy to evaluate their existing curricula. An issue frequently encountered is the limited amount of content in the pharmacy curriculum specific to managed care and the role and function of pharmacy benefit management companies (PBMs).

OBJECTIVE

To determine pharmacy student knowledge and opinions about managed care pharmacy, including the function of PBMs in the delivery of health care, in a college of pharmacy, and to explore tendencies in communication between pharmacy interns and patients in the community setting.

METHODS

Students from all 4 PharmD years (n = 663) in 1 college of pharmacy were invited to complete an online survey consisting of 19 questions on demographics, students' views and understanding of PBMs, and interest in working at a PBM in their career. Follow-up in-person and online focus group sessions with representatives from each pharmacy class year were conducted to collect information from students regarding views and understanding of managed care pharmacy. Focus group data were analyzed using a constant comparative method by 2 independent researchers.

RESULTS

Of 374 respondents, 332 (88.8%) answered all of the survey questions and were included in the analysis. Most students (72.0%) indicated that they understand little or nothing about the functions of PBMs; 84.3% rated the amount that they had been taught about PBMs in pharmacy school as "inadequate" or "very inadequate;" and 45.2% indicated little or no interest in a PBM career. Yet, 34.7% (99 of 285) of students with past or current community pharmacy work experience rated the percentage of time that PBMs directly affected their practice worksite during a shift at 50% or greater. Focus group emerging themes confirmed survey data findings that students feel uninformed about managed care but regularly communicate with patients about managed care issues. Focus group findings also suggest that students may perceive managed care to be a "masculine," "uncaring" field.

CONCLUSIONS

In an exploratory survey conducted at 1 pharmacy school, students perceived themselves as generally uninformed about managed care issues, yet more than one-third believed that dealing with PBMs constituted a significant portion of their work day as community-based pharmacy interns. Managed care understanding is necessary for all pharmacy students because most graduates will practice in community settings. Patients are exposed to managed care and their pharmacy benefit primarily at the point of medication procurement and medication counseling. As a result, pharmacists provide many patients with managed care and pharmacy benefit education. Schools of pharmacy may wish to evaluate and consider increasing the amount of curriculum content specific to managed care and PBMs.

An online elective course for undergraduate students on common prescription medications

OBJECTIVES

To design, implement, and evaluate an online elective course on common prescription medications for undergraduate (pre- and non-health professional) students.

DESIGN

An 8-module online course on common prescription medications was designed following the ADDIE (Analysis, Design, Development, Implementation, and Evaluation) instructional design model and offered to students for 8 consecutive semesters.

ASSESSMENT

Following each offering, performance data were analyzed and a course review conducted, including evaluation of entrance survey data and course evaluations. Direct analysis of data over 2 offerings and grade distribution comparisons over all 8 offerings, demonstrated consistent knowledge gains. Feedback from course evaluations and a continual increase in enrollment over the 8 semesters indicated student satisfaction with the course.

CONCLUSION

Systematic design and quality assurance/improvement strategies resulted in the successful establishment of an online pharmacotherapy course for undergraduate, nonpharmacy students.

Single-dose pharmacokinetics and safety of pegylated interferon-alpha2b in patients with chronic renal dysfunction

This study evaluates the pharmacokinetics and safety of pegylated interferon-alpha2b (PEG-Intron) following a single-dose subcutaneous injection into subjects with normal renal function, subjects with chronic renal impairment, and patients on hemodialysis. In this open-label, single-dose, parallel group study, subjects were divided into five groups according to their degree of renal function: four groups as defined by measured creatinine clearance and a fifth hemodialysis dependent group. They received 1 microg/kg PEG-Intron subcutaneously after a 10-hour fast. Pharmacokinetic and safety assessments were performed up to 168 hours postdose. Hemodialysis patients had a second PEG-Intron dose 12 hours prior to a hemodialysis session. PEG-Intron pharmacokinetic parameters (AUCtf, Cmax, and t1/2) increased progressively as CL(CR) declined. All subjects reported at least one adverse event, which were typical of those reported after alpha-interferon administration (e.g., flu-like symptoms, headache). Single-dose PEG-Intron administration to volunteers with normal renal function and chronic renal impairment was safe and well tolerated. In patients with CL(CR) < 30 ml/min, AUCand Cmax values were increased 90% compared with controls, while half-life was increased by up to 40% over controls. Based on the relationship between PEG-Intron apparent clearance and CL(CR), renal clearance accountsfor less than half of its total clearance. Hemodialysis did not affect PEG-Intron apparent clearance.

Intravenous and subcutaneous weight-based dosing of the low molecular weight heparin tinzaparin (Innohep) in end-stage renal disease patients undergoing chronic hemodialysis

BACKGROUND

Patients with end-stage renal disease are subject to a broad range of thrombotic complications. Low molecular weight heparins (LMWHs) are effective antithrombotic agents; however, they are cleared largely by renal mechanisms, raising uncertainty about their use in renally impaired patients.

METHODS

Twelve chronic hemodialysis subjects were administered two single doses of the LMWH tinzaparin, 75 IU/kg, 2 weeks apart: subcutaneously (SC) on an off-dialysis day and intravenously (IV) just before dialysis.

RESULTS

Mean maximal anti-factor Xa (anti-Xa) activity was 0.33 IU/mL 4.0 hours after SC administration and 1.33 IU/mL 0.25 hours after IV administration. Anti-Xa half-lives were 3.89 and 2.31 hours, respectively. Anti-Xa activity returned to baseline within 24 hours of administration by either route. Consistent with population pharmacokinetic analyses of clinical study subjects with severe renal impairment, anti-Xa clearance after tinzaparin administration was reduced 28% relative to subjects with normal renal function. All 12 study subjects completed hemodialysis without requiring additional anticoagulation. One subject had minimal clotting in the dialyzer drip chamber, and one subject had mild prolonged bleeding at the vascular access site after dialysis needle removal. No major bleeding events occurred.

CONCLUSION

Tinzaparin, 75 IU/kg, SC on an off-dialysis day and IV just before dialysis is well tolerated in chronic hemodialysis patients. The weight-based regimen of 75 IU/kg IV just before dialysis provides adequate anticoagulation. SC weight-based dosing on off-dialysis days is a feasible regimen for further clinical thromboprophylaxis efficacy studies in hemodialysis patients. The risk for clinical overdose in severely renally impaired patients using this weight-based regimen of tinzaparin is unlikely.

Dehydroepiandrosterone, dehydroepiandrosterone-sulfate, and cortisol concentrations in intensive care unit patients

STUDY OBJECTIVE

This purpose of this study was to determine whether severity of illness, as defined by the intensive care unit (ICU) admission APACHE II (updated Acute Physiology and Chronic Health Evaluation) score, is correlated with early morning cortisol, dehydroepiandrosterone (DHEA), and/or dehydroepiandrosterone-sulfate (DHEA-S) concentrations.

DESIGN

Early morning concentrations of DHEA, DHEA-S, and cortisol were determined within 24 hrs of admission and compared with admission APACHE II scores.

SETTING

Medical (MICU), neurologic (NICU), and surgical (SICU) intensive care units of the University of Pittsburgh Medical Center.

PATIENTS

A total of 191 men and women ranging in age from 16 to 93 yrs. All had been admitted to an ICU.

MEASUREMENTS AND MAIN RESULTS

Statistically significant correlations between APACHE II scores and cortisol were observed for women in the MICU and SICU (r = .68, p = .0001; r = .35 p = .017, respectively) and for men in the NICU (r = .55, p = .003) and the SICU (r = .29, p = .036). The correlations between APACHE II scores and DHEA concentration data were statistically significant for women in the MICU (r = .37, p = .047) and SICU (r = .43, p = .002), as was the correlation between APACHE II and DHEA-S concentrations among women in the SICU (r = .38, p = .008). Although not statistically significant, a similar relationship was observed in the smaller group of NICU women (r = .40, p = .099). Each correlation was essentially unchanged when adjusted for age.

CONCLUSION

These data show a positive correlation between APACHE II and cortisol concentrations in all groups except the MICU men. Also evident is the positive correlation between APACHE II scores and DHEA and DHEA-S concentrations in women, but not in men.

DHEA and DHEA-S: a review

Dehydroepiandrosterone (DHEA) and its sulfated metabolite DHEA-S are endogenous hormones secreted by the adrenal cortex in response to adrenocorticotrophin (ACTH). Much has been published regarding potential effects on various systems. Despite the identification of DHEA and DHEA-S more than 50 years ago, there is still considerable controversy as to their biological significance. This article reviews the metabolism and physiology of DHEA and DHEA-S, the influence of age and gender on concentrations, and changes in endogenous concentrations associated with disease states and other factors, including diet and exercise. This article is unique in that it also summarizes the influence of drugs on DHEA and DHEA-S concentrations, as well as concentrations of DHEA and DHEA-S observed after the administration of DHEA by various routes. Sections of the article specifically address DHEA and DHEA-S concentrations as they relate to stress, central nervous system function and psychiatric disorders, insulin sensitivity, immunological function, and cardiovascular disorders.

Pharmacokinetics and pharmacodynamics of triazolam after two intermittent doses in obese and normal-weight men

This study was designed to determine whether differences in alpha-1 acid glycoprotein and free drug concentrations result in an altered response to triazolam. Twelve normal-weight and 12 obese adult male subjects received intravenous doses of triazolam, 0.5 mg, on two occasions separated by 1 week. There was a small difference in the alpha-1 acid glycoprotein concentrations between groups but no difference in free fraction of triazolam. There was a longer terminal half-life (t1/2 beta) in the obese subjects (3.16 +/- 0.87 vs. 3.83 +/- 1.24, p = 0.0098). Overall, week 1 data revealed no difference in effect between normal and obese subjects. However, response data reveal a pattern of increased sensitivity with the second exposure to triazolam. For example, area under the effect curve (AUEC) on all tests was significantly greater in week 2 for both groups of subjects. For a memory test and sedation from 0 to 12 hours, AUEC/free AUC ratios were significantly greater in week 2 for all subjects. The obese had a higher ratio on week 2 than on week 1 for all psychomotor tests and sedation (0 to 4.5 hours; p < 0.05). The results of modeling psychomotor impairment-concentration data pooled by group for each week continue the pattern: week 1 data are similar between the obese and normal-weight subjects. Although EC50 values are up to 15% lower in week 2 for the normal-weight subjects, EC50 values are as much as 66% lower in week 2 for the obese, where a lower EC50 indicates greater sensitivity. Logistic regression of the recognition data is consistent with these results.(ABSTRACT TRUNCATED AT 250 WORDS)