ASHP and ASHP Foundation Pharmacy Forecast 2024: Strategic Planning Guidance for Pharmacy Departments in Hospitals and Health Systems

Purpose: The 2024 ASHP Pharmacy Forecast identifies and contextualizes emerging issues and trends that will influence healthcare, health systems, and the pharmacy profession and provides recommendations to inform long-term strategic planning that should prompt action by pharmacists and health-system leaders. Methods: Drawing on the “wisdom of crowds” concept, a survey was constructed with 6 general themes, each with 6 to 9 focused statements and a seventh theme on preparedness (58 survey items in total). The size of and representation within the survey panel were intended to capture opinions from a wide range of pharmacy leaders. The survey instructed panelists to consider the likelihood of the events/scenarios described in the statements occurring in the next 5 years as being likely, somewhat likely, somewhat unlikely, or very unlikely. Then, survey panelists assessed the preparedness (from very unprepared to very prepared) for 12 of the statements. Results: The 6 survey themes identified were Urgent Public Health Priorities, Responding to the Mental Health Crisis, Achieving Care Equity, New Disease Paradigms and Treatment Innovations, Workforce: Focus on Culture for the Future, and Artificial Intelligence: Can Ethics and Regulators Catch Up? The survey was completed by 250 respondents, yielding an 88% response rate. Analysis of survey results was provided by chapter authors along with strategic recommendations to guide actions for each theme. Conclusion: The focus of the Pharmacy Forecast is on large-scale, long-term trends that will influence healthcare and the pharmacy profession over months and years and not on day-to-day situational dynamics. The report provides insight to stimulate thinking and discussion and provides a starting point to proactively position leaders, their teams, and departments for potential future events and trends.

Cost-effectiveness of apixaban versus other oral anticoagulants and aspirin for stroke prevention in atrial fibrillation in indian subcontinent

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): Pfizer Ltd

Background/Introduction

Non-vitamin K antagonist oral anticoagulants (NOACs) are class I recommended by various guidelines for stroke prevention in atrial fibrillation. NOACs are associated with comparable or lower risk of stroke / systemic embolism and significantly lower major bleeding as compared to VKAs. Despite the fact that NOACs have demonstrated safety and efficacy in stroke prevention in AF by various randomized clinical trials and real-world evidences, the pharmacoeconomic data of NOACs in stroke prevention is lacking in India. In view of the higher initial and long-term cost of the NOAC therapy, it is important to analyze the cost effectiveness of such therapy to ensure wider acceptance and compliance to medication since majority of population in India is self-paying.

Purpose

The aim of this study was to evaluate the cost-effectiveness of apixaban versus other NOACs available in India (dabigatran and rivaroxaban), warfarin and aspirin for stroke prevention in atrial fibrillation from the healthcare providers’ and patients’ perspectives in the government healthcare as well as the private healthcare facilities across Indian subcontinent.

Methods

A Markov model was constructed using six-week cycle length over a lifetime horizon by including the available data from RCTs and real-world analyses of all NOACs. The clinical consequences of AF included in the analysis were stroke (ischemic and hemorrhagic), systemic embolism, bleeding (intracranial hemorrhage, other major and clinically relevant non-major), myocardial infarction, mortality and morbidity associated with NVAF not on anticoagulant. Innovator brands of NOACs were considered for this analysis, as NOACs are not under price control in India unlike warfarin and aspirin. Model outputs included quality-adjusted life years (QALY), life years gained, direct medical costs and incremental cost-effectiveness ratios (ICERs). Additional sensitivity and scenario analyses were conducted to test the robustness of the outcomes.

Results

From healthcare provider’s perspective irrespective of private medical facility or the government healthcare facilities, Apixaban was dominantly associated with cost-saving over other OACs. Apixaban was cost effective as compared to warfarin from patients’ perspective at the private medical facilities. Apixaban was cost-effective compared to dabigatran and rivaroxaban from patients’ perspective in the RWE-based analysis.

Conclusion

We conclude that apixaban is cost saving (less costly and more effective) compared to warfarin, aspirin and other NOACs from healthcare providers’ perspective. Apixaban may be a cost-effective alternative to dabigatran and rivaroxaban from patients’ perspective as per the RWD-based cost-effectiveness analysis. These conclusions are based on indirect comparisons, but despite this limitation, the information is useful for healthcare professionals and decision-makers. Abstract Figure. Incremental cost-effectiveness ratios

Belatacept and Eculizumab for Treatment of Calcineurin Inhibitor-induced Thrombotic Microangiopathy After Kidney Transplantation: Case Report

Thrombotic microangiopathy (TMA) after kidney transplantation is an uncommon and challenging cause of graft dysfunction and is associated with early graft loss. An idiosyncratic endothelial reaction to calcineurin inhibitors (CNIs) has been implicated as a frequent cause of TMA. This reaction is marked by uncontrolled activation of complement and subsequent cellular destruction. Usual therapy consists of withdrawal of the inciting drug and plasmapheresis to minimize levels of circulating complement. Recently, eculizumab, a monoclonal antibody to complement component C5, has been used for the treatment of atypical hemolytic uremic syndrome. Belatacept, an inhibitor of T cell costimulatory protein CTLA-4 has been used in immunosuppression strategies aimed at minimization of CNI. Here we report the first case of treatment of CNI-associated TMA/hemolytic uremic syndrome with withdrawal of tacrolimus and initiation of both belatacept and eculizumab. The case describes a favorable clinical course for both graft and patient, and is accompanied by a review of the literature.

Protecting genomic integrity in somatic cells and embryonic stem cells

Mutation frequencies at some loci in mammalian somatic cells in vivo approach 10(-4). The majority of these events occur as a consequence of loss of heterozygosity (LOH) due to mitotic recombination. Such high levels of DNA damage in somatic cells, which can accumulate with age, will cause injury and, after a latency period, may lead to somatic disease and ultimately death. This high level of DNA damage is untenable for germ cells, and by extrapolation for embryonic stem (ES) cells, that must recreate the organism. ES cells cannot tolerate such a high frequency of damage since mutations will immediately impact the altered cell, and subsequently the entire organism. Most importantly, the mutations may be passed on to future generations. ES cells, therefore, must have robust mechanisms to protect the integrity of their genomes. We have examined two such mechanisms. Firstly, we have shown that mutation frequencies and frequencies of mitotic recombination in ES cells are about 100-fold lower than in adult somatic cells or in isogenic mouse embryonic fibroblasts (MEFs). A second complementary protective mechanism eliminates those ES cells that have acquired a mutational burden, thereby maintaining a pristine population. Consistent with this hypothesis, ES cells lack a G1 checkpoint, and the two known signaling pathways that mediate the checkpoint are compromised. The checkpoint kinase, Chk2, which participates in both pathways is sequestered at centrosomes in ES cells and does not phosphorylate its substrates (i.e. p53 and Cdc25A) that must be modified to produce a G1 arrest. Ectopic expression of Chk2 does not rescue the p53-mediated pathway, but does restore the pathway mediated by Cdc25A. Wild type ES cells exposed to ionizing radiation do not accumulate in G1 but do so in S-phase and in G2. ES cells that ectopically express Chk2 undergo cell cycle arrest in G1 as well as G2, and appear to be protected from apoptosis.

A Case of Severe Thrombocytopenia and Antiepileptic Hypersensitivity Syndrome

Thrombocytopenia is a known complication of antiepileptic drug therapy. We present a case of a 3-year-old child who developed fever, rash, and severe thrombocytopenia within 10 days of initiating therapy with carbamazepine for new onset epilepsy. The patient's thrombocytopenia resolved following discontinuation of carbamazepine and introduction of valproic acid, however, his seizure disorder became poorly controlled. Phenobarbital was added to valproic acid therapy, which resulted in reoccurrence of fever, rash, and thrombocytopenia consistent with antiepileptic hypersensitivity syndrome. Discontinuation of phenobarbital, valproic acid and introduction of zonisamide resulted in resolution of his symptoms. The potential etiologies of thrombocytopenia in this case include carbamazepine-induced antiepileptic hypersensitivity syndrome, phenobarbital-induced antiepileptic hypersensitivity syndrome as a result of cross-reactivity with carbamazepine, and/or dose-dependent thrombocytopenia caused by valproic acid therapy. The pathogenesis and cases of aromatic anticonvulsant-induced immune-mediated thrombocytopenia are discussed. Alternative therapies for antiepileptic hypersensitivity syndrome with thrombocytopenia include gabapentin, levetiracetam, tiagabine, topiramate, and zonisamide.