Preparing student-pharmacists to utilize motivational interviewing techniques to address COVID-19 vaccine hesitancy in underrepresented racial/ethnic patient populations

BACKGROUND AND PURPOSE

Vaccine hesitancy disproportionally impacts racial/ethnic minority populations. Regarded as trusted, accessible, and knowledgeable, pharmacists are strategically positioned to address this threat using effective communication strategies such as motivational interviewing (MI). Little data exists on programs that prepare student-pharmacists to use MI to combat vaccine hesitancy in underrepresented populations.

EDUCATIONAL ACTIVITY AND SETTING

Student pharmacists elected to participate in co-curricular training on addressing COVID-19 vaccine hesitancy in racial/ethnic minority populations. The training included a web-based module on using MI to address COVID-19 vaccine hesitancy and a live group objective structured clinical examination (OSCE) with standardized patient encounters that included prevalent COVID-19 vaccine concerns. Faculty assessed the group's ability to employ core elements of MI to correct vaccine misinformation. After the OSCE, students received feedback from the standardized actors and evaluators. Change in student confidence was assessed. After the training, students volunteered at eight different community events to utilize MI to address vaccine hesitancy in underrepresented patient populations.

FINDINGS

A total of 17 students completed the training. Four out of the six groups received a passing score on the OSCE. Students performed satisfactory in the major domains of MI but struggled to answer knowledge-based questions regarding COVID-19 vaccines. As a result of the training, a significant increase in student confidence was seen. All participating students rated the training as either "excellent" or "good."

SUMMARY

A novel, co-curricular educational initiative was an effective tool to prepare student-pharmacists to utilize MI to combat vaccine hesitancy in underrepresented racial/ethnic minority populations.

Emerging therapies for the treatment of nonalcoholic steatohepatitis: A systematic review

To describe the mechanism, efficacy, and safety of novel agents that have reached phase 3 clinical trials for the treatment of biopsy-proven nonalcoholic steatohepatitis (NASH). A literature search was conducted using the PRISMA guidelines of MEDLINE databases (1990 to October 2020) with the following MeSH terms: NASH, nonalcoholic liver disease, fatty liver, liver diseases, steatohepatitis, liver fibrosis; combined with obeticholic acid, FXR agonist, cenicriviroc, CCR5 receptor antagonist, elafibranor, PPAR, selonsertib, ASK-1 inhibitor, resmetirom, THR-β receptor, arachidyl amido cholanoic acid (Aramchol™), and SCD-1 modulator. Results were verified via clinicaltrials.gov, Google Scholar, and Google. Articles were included if the medications of interest had ongoing or completed phase 3 trials in biopsy-proven NASH with outcomes directly related to NASH resolution. Eleven studies were identified involving obeticholic acid (OCA), elafibranor, cenicriviroc, Aramchol, and resmetirom. Two agents have reported data from phase 3 trials: OCA and elafibranor. OCA demonstrated safety and efficacy in NASH with a primary end point of improvement or NASH resolution; a new drug approval has been submitted. Elafibranor failed to show efficacy in NASH in the preliminary report from the RESOLVE-IT trial; however, the study is being extended to reassess outcomes. The remaining agents demonstrated positive results in phase 2b studies and have initiated phase 3 trials. With projections for increased prevalence of patients with NASH and the current lack of treatment options, novel agents with targeted mechanisms could potentially change the treatment landscape. The manufacturer of OCA is first to submit a new drug application for the treatment of NASH. These novel agents may fill a pharmacotherapy gap in patients with NASH and possibly prevent progression to advanced liver disease.

Impact of Pharmacy-Led Education Regarding Multimodal Acute Pain Management on Medical Residents’ Prescribing of Opioids

Background:

Opioids are commonly prescribed for patients with acute pain. Guidelines recommend multimodal regimens to synergistically treat pain and provide enhanced recovery.

Objective:

The objective of this study was to assess changes in oral morphine milligram equivalents (MMEs) prescribed by internal medicine (IM) medical residents for acute pain after a series of pharmacist-led in-services on prescribing multimodal pain regimens.

Methods:

Two hundred patients were assessed for changes in oral MMEs prescribed prior to and after a 3-part in-service series on multimodal pain management. Inclusion criteria included those who were admitted with acute pain managed by an IM resident, were prescribed analgesic(s), and were 18 years and older. Patients excluded were those admitted into the intensive care unit, receiving chronic pain management, obstetric patients, cancer patients, patients with previous opioid exposure, and patients using patient-controlled analgesia. The study outcomes were change in oral MMEs prescribed by medical residents for acute pain after the in-services, multimodal regimen use, appropriate analgesics prescribed, prescribing a bowel regimen if the patient was prescribed an opioid, and prescribers’ survey results.

Results:

A total of 6358.6 oral MMEs were prescribed before and 5297 oral MMEs were prescribed after the in-services. Fifty-eight patients before and 70 patients after the in-services were prescribed a multimodal regimen. Ten patients before and 18 patients after the in-services were given a bowel regimen. Eighty percent of the patients before and 85% after the in-services had an appropriate pain scale for their prescriptions. IM medical resident and student survey scores improved after each in-service.

Conclusion:

An educational series on multimodal regimens for acute pain management decreased opioid prescription and increased the use of multimodal regimens for acute pain.

A Systematic Review of Newer Antidiabetic Agents in the Treatment of Nonalcoholic Fatty Liver Disease

OBJECTIVE

To evaluate glucagon-like peptide 1 receptor agonists (GLP-1 RAs), dipeptidyl-peptidase IV (DPP-4) inhibitors, and sodium-glucose cotransporter 2 (SGLT) inhibitors to treat nondiabetic and type 2 diabetes mellitus (T2DM) nonalcoholic fatty liver disease (NAFLD) as it relates to improvement in hepatosteatosis (HS) or steatohepatitis (SH).

DATA SOURCES

MEDLINE and CINAHL were searched from inception through May 1, 2020. Search terms included nonalcoholic steatohepatitis, nonalcoholic fatty liver disease, fatty liver, dipeptidyl-peptidase IV inhibitors, glucagon-like peptide-1 receptor agonists, and sodium-glucose transporter 2 inhibitors.

STUDY SELECTION AND DATA EXTRACTION

Full-text observational and randomized controlled studies in English were included. Patients diagnosed with NAFLD, treated with GLP-1 RAs, DPP-4 inhibitors, and SGLT2 inhibitors, with measures to evaluate HS or SH were evaluated.

DATA SYNTHESIS

Eight GLP-1 RA trials were reviewed; 7 GLP-1 RA trials showed improvement in HS. Two studies demonstrated improvement in liver histology in patients with SH. Seven SGLT2 inhibitor studies were reviewed; 6 studies demonstrated improvements in NAFLD. Five studies showed improvements in HS, whereas 1 displayed improvement in liver histology in NASH. Six studies that included DPP-4 inhibitors were evaluated, and only 2 demonstrated improvement in NASH.

RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE

Based on evidence reviewed, GLP-1 RAs and SGLT2 inhibitors decreased HS and SH in NAFLD patients, whereas DPP-4 inhibitor therapy was not effective for patients with HS.

CONCLUSIONS

Based on study data utilizing imaging studies and biopsy results, GLP-1 RAs or SGLT2 inhibitors can benefit NAFLD T2DM patients. Clinical trials with larger patient populations may augment these results.

Developing a comprehensive APPE-readiness plan with a focus on skills, attitudes, and behaviors

BACKGROUND AND PURPOSE

Pharmacy schools must have a framework to ensure students have the necessary knowledge, skills, attitudes, and behaviors to be successful during advanced pharmacy practice experiences (APPEs).

EDUCATIONAL ACTIVITY AND SETTING

Ten summative assessments, called APPE-readiness assessments (ARAs), were developed based on eight competencies encompassing skills, behaviors, and attitudes that must be demonstrated prior to APPEs. All eight competencies were assessed in the course Case Studies in Pharmacotherapy IV, which is offered in the final semester of the didactic curriculum immediately prior to APPEs. A 15-question pre- and post-survey was conducted to assess student confidence in performing each APPE-readiness competency. Cohort data was evaluated by the curriculum and assessment committee to assess curriculum effectiveness and areas for improvement.

FINDINGS

Upon completion of the course, the average first-attempt pass rate across all ARAs was 92.4%. All students who failed on the first attempt passed on the second attempt, thereby demonstrating APPE-readiness. Out of 62 students, 45 and 44 completed the pre- and post-survey, respectively. Prior to the ARAs, the overall average of students who felt (strongly) confident about their ability to perform each competency was 82.2 ± 2.1%. This increased to 92.6 ± 1.6% after the ARAs.

SUMMARY

The development of an APPE-readiness assessment plan focusing on skills, attitudes, and behaviors provides insight into student and cohort performance and allows for continuous quality assurance of the pre-APPE curriculum.

Vitamin C, Thiamine, and Steroids in the Sepsis Conquest: Replete to Defeat

PURPOSE

Sepsis and septic shock are significant health issues in the United States. Novel treatment options focusing on mitigating the dysregulated host response while reducing the need for vasopressor support are needed. This review discusses ascorbic acid, thiamine, and steroids as monotherapy and in combination for the treatment of sepsis and septic shock.

SUMMARY

The results of clinical studies using ascorbic acid, thiamine, and steroids as monotherapy or in combination are reviewed. High doses of IV ascorbic acid improved organ failure evidenced by changes in SOFA scores, declining CRP and PCT levels, and reduced vasopressor use. Thiamine initiation improved lactate levels in thiamine deficient patients in one study and demonstrated quicker lactate clearance and lower 28-day mortality in another study. Steroid studies demonstrated greatest benefit when initiating hydrocortisone and fludrocortisone early in septic shock. Combination therapy with ascorbic acid, thiamine and steroids reduced hospital mortality and vasopressor use in sepsis and septic shock in a small single-center study.

CONCLUSION

Initial studies in patients with sepsis and septic shock demonstrated beneficial effects of ascorbic acid, thiamine, and steroids as monotherapy or in combination without safety concerns. However, the efficacy and safety of these therapies warrant further validation in larger clinical studies.

Treatment of Severe Alcohol Withdrawal: A Focus on Adjunctive Agents

Objective:To review adjunctive treatment options for severe alcohol withdrawal. Data Sources: The search strategy included a search of Ovid MEDLINE using keywords alcohol withdrawal, severe alcohol withdrawal, AWS, delirium tremens, delirium, dexmedetomidine, propofol, anticonvulsants, clonidine, and phenobarbital and included articles dated from January 1990 to March 2017. Study Selection and Data Extraction: All English-language clinical trials and case reports assessing the efficacy of adjunctive agents in severe alcohol withdrawal were evaluated. Data Synthesis: Although first-line pharmacotherapy for alcohol withdrawal continues to be benzodiazepines, literature does not clearly define adjunctive treatment options for severe alcohol withdrawal. During severe alcohol withdrawal patients may become unable to tolerate or may become unresponsive to high-dose benzodiazepines. Large doses of benzodiazepines may also result in oversedation, respiratory insufficiency, and worsening delirium. Conclusions: Phenobarbital and dexmedetomidine are both viable adjunctive treatment options for severe alcohol withdrawal. Current evidence has shown these agents decrease the dose requirements of benzodiazepines with limited incidence of adverse reactions. Propofol may also be a viable option in mechanically ventilated patients, but its lack of clear safety and efficacy advantages over current treatment options may limit its use in practice. Clonidine, oral anticonvulsants, and ketamine require further controlled clinical trials to clearly define their role in the treatment of severe alcohol withdrawal.

A New Mechanism of Action in Heart Failure: Angiotensin-Receptor Neprilysin Inhibition

Objective: To evaluate the efficacy, safety, and clinical significance of sacubitril/valsartan (Entresto) in patients with heart failure with a reduced ejection fraction (HFrEF). Data Sources: An extensive search was conducted on Ovid MEDLINE using keywords and medical subject headings LCZ696, sacubitril/valsartan, angiotensin-receptor neprilysin inhibitor, and Entresto. Study Selection and Data Extraction: The search was conducted to retrieve clinical trials comparing sacubitril/valsartan to current guideline-directed therapy for HF. Articles using the limits of clinical trials "all" (phase I to IV), in English, and published within the past 5 years were reviewed. Supplemental sources included the Entresto package insert via the manufacturer's website. Primary end points included all-cause mortality and time to first hospitalization. Safety end points included incidence and severity of angioedema, cough, hyperkalemia, increased serum creatinine, and hypotension. Data Synthesis: This review critiques both clinical and statistical significance of the "Prospective Comparison of ARNi with ACEI to Determine Impact on Global Mortality and Morbidity in Heart Failure" or PARADIGM-HF and other phase II to III clinical trials. Sacubitril/valsartan showed a 20% reduction in cardiovascular death and first hospitalization from HF compared with enalapril. Despite an overall reduction in adverse events, sacubitril/valsartan had increased occurrences of hypotension and nonserious angioedema. Conclusion: Sacubitril/valsartan is a viable option for newly diagnosed New York Heart Association (NYHA) class II to III and is an alternative to patients who are currently being treated with the maximum doses of current gold standard treatment. Clinicians initiating sacubitril/valsartan must monitor patients closely for signs, symptoms, and history of hypotension and angioedema.

Establishing Edoxaban’s Role in Anticoagulation

Purpose

This article serves as a review of the current literature regarding the role of edoxaban for the prevention of stroke in patients with nonvalvular atrial fibrillation (AF) and the treatment of venous thromboembolism (VTE).

Summary

Until recent years, oral treatment options for both treatment and prevention of VTE and stroke were limited to warfarin. Dabigatran was the first new oral anticoagulant approved in over 50 years followed by rivaroxaban and apixaban. These new oral anticoagulants offer many benefits over warfarin. Edoxaban is the newest member among the oral anticoagulants and exerts its action by direct inhibition of factor Xa. It may offer some advantages in that it is the second Food and Drug Administration-approved once-daily anticoagulant available and does not interact with the cytochrome P450 (CYP450) system. However, there are concerns in patients with AF and preserved renal function (>95 mL/min), as these cohorts experienced a higher incidence of stroke in trials.

Conclusion

Based on the 3 clinical trials, edoxaban appears to be a safe and effective factor Xa inhibitor in patients with a creatinine clearance of <95 mL/min. It will serve as an alternative anticoagulant for those with a preference for once-daily dosing and/or taking medications that interact with the CYP450 system.

Preventing medication errors in transitions of care: A patient case approach

OBJECTIVE

To discuss common causes of medication errors occurring upon transitions of care and review key interventions that should be implemented to ensure effective communication and accurate completion of medication reconciliation.

DATA SOURCES

MEDLINE (1946 to November 2014) using MeSH terms medication errors, medication reconciliation, and nursing homes in addition to conventional text words, including transitions of care and medication safety; Agency for Healthcare Research and Quality Patient Safety Network using search terms transitions of care, medication errors, and medication reconciliation; and relevant websites of national organizations pertaining to transitions of care and medication reconciliation.

STUDY SELECTION

Limited to English-language journals with no limitation set on the year of publication for clinical trials, meta-analyses, and reviews.

DATA EXTRACTION

At the authors' discretion, preference was given to references focusing on pharmacists' role in transitions of care and medication reconciliation.

RESULTS

Most medication errors stem from a lack of effective communication between health care providers during transitions of care. Part of successful communication and correct patient hand-off is completing accurate medication reconciliation. A patient case highlights a life-threatening medication error that occurred during a transition of care due to ineffective communication between a pharmacist and nurse while transferring medication information.

CONCLUSION

To provide patients with accurate medication information, pharmacists should perform medication reconciliation upon transitions of care using The Joint Commission's five-step process. Pharmacists can conduct numerous interventions to prevent medication errors during transitions of care and ensure patient safety. Pharmacists are integral to evaluating the appropriateness of medication use, ensuring information is updated in the health record, and verbally communicating accurate information to other health professionals.

Dapsone Hypersensitivity Syndrome in a Patient With Acquired Immunodeficiency Syndrome

Objective: A case of dapsone hypersensitivity syndrome (DHS) in an AIDS patient receiving dapsone for Pneumocystis pneumonia (PCP) prophylaxis is discussed. Case Summary: A 50-year-old Caucasian male with a history of AIDS was admitted with suspicion of pneumonia. The clinical presentation consisted of shortness of breath, occasional hemoptysis, odynophagia, skin rash, transaminitis, anemia, malaise, and peripheral neuropathy. His medications included nystatin, fluconazole, valacyclovir, and pantoprazole. For PCP prophylaxis, the patient was initiated on dapsone 100 mg daily approximately 4 weeks prior to admission. The patient was also on a 3-drug regimen for the treatment of mycobacterium avium complex: clarithromycin, rifabutin, and ethambutol. After extensive work up, DHS was diagnosed. Dapsone was immediately discontinued and the patient was started on intravenous methylprednisolone, gradually tapered, and transitioned to oral prednisone. On discontinuation of dapsone, the patient improved, evidenced by decreased need for oxygen and reversal of peripheral neuropathy, anemia, and transaminitis. The patient’s skin rash improved within a few days. An objective causality assessment, with the Naranjo scale, suggests that DHS was probably related to dapsone. Discussion: Our patient only exhibited some of the classic symptoms observed in DHS such as skin eruptions, malaise, hepatic failure, and hemolytic anemia. The patient, however, did not present with lymphadenopathy and fever commonly noted in DHS, which may be attributed to his immunosuppressed state, evidenced by a CD4 count of 7 cell/mm3. Conclusions: A patient on dapsone for PCP prophylaxis was diagnosed with DHS. Clinicians and patients should be educated on risk factors and clinical presentation of DHS so that when initial symptoms appear they can be treated promptly. Clinicians should also be aware that patients infected with HIV/AIDS may not present with all the classic symptoms of DHS due to their immunocompromised state. Therefore, practitioners should be vigilant when initiating dapsone in this patient population.

Holter monitoring

Twenty-four hour electrocardiographic (Holter) monitoring has been adopted in primary care for the assessment of patients with suspected cardiac arrhythmias. This article examines the clinical use of the Holter monitoring technique, outlines the range of arrhythmias recorded in healthy adults, and evaluates the merit of the investigation in a primary-care clinical setting. Holter monitoring is most valuable in assessing symptomatic patients with known coronary artery disease of in the postinfarction period. Although frequent and complex arrhythmias in such patients may be associated with sudden death, it is not yet known whether treatment decreases mortality.

Hirschsprung's Disease: A Review

Constipation is a common symptom in infants and young children who are seen by primary care physicians. If a patient fails to respond to the appropriate medical therapy for constipation, then the physician should consider the possibility of Hirschsprung's disease, a congenital disease in which ganglion cells are absent from the distal gastrointestinal tract, and which results in a functional colonic obstruction. Early diagnosis and prompt treatment of Hirschsprung's disease will result in a significantly improved quality of life for the patient, and may alleviate potentially life-threatening complications. This article describes a case of Hirschsprung's disease and reviews the most current literature on the topic. Clinical features that distinguish Hirschsprung's disease from other causes of constipation are emphasized.