Tirzepatide for type 2 diabetes

One in ten adults worldwide is living with diabetes, with 95% having type 2 diabetes (T2D). Sustained glycaemic control in people with T2D is difficult to achieve despite recent advances in T2D management with the advent of glucagon-like peptide 1 receptor agonists (GLP1RA) and sodium-glucose cotransporter 2 inhibitors (SGLT2i). Tirzepatide represents a first-in-class agent as a dual glucose-dependent insulinotropic polypeptide (GIP)/GLP1RA to be approved in the USA and Europe for the treatment of T2D. This narrative review intends to list and discuss the glycaemic efficacy, key safety and weight loss outcomes related to the treatment of T2D with tirzepatide. Tirzepatide has been evaluated in five published clinical trials (n=6278) within the SURPASS clinical trial programme, with a focus on glycaemic control and weight loss. These trials have demonstrated significant improvements in glycosylated haemoglobin (-1.24% to -2.11% versus placebo and -0.6% to -1.14% versus active comparator) and weight (up to 15.5 kg versus placebo or active comparator) in patients with T2D. Notably, tirzepatide exhibited superior glycaemic control and weight loss when compared directly with a GLP1RA. Adverse events with the use of tirzepatide are similar to other approved GLP1RA and are predominantly gastrointestinal (nausea, vomiting). The tirzepatide cardiovascular outcomes trial (SURPASS-CVOT) is in progress and is expected to be completed in the fall of 2024. Tirzepatide represents an attractive new option and first-in-class agent for the treatment of T2D in people unable to achieve their glycaemic or weight management goals.

Examining the Directionality of the Relationship Between Maternal Warmth and Early School-Age Anxiety

Maternal warmth has been identified as a contributing factor to the development of child anxiety; however, no studies to date have examined observed maternal warmth longitudinally in this relationship. The present study addressed this knowledge gap by examining the simultaneous development of maternal warmth and child anxiety over time (between-person effects using latent growth curve modeling) and the directionality of associations (within-person effects using autoregressive latent trajectory modeling). Participants included 753 mothers and children. Between-person effects indicated that lower initial levels of anxiety were related to greater levels of maternal warmth over time. Within-person effects showed that maternal warmth in grade 1 predicted subsequent decreases in child anxiety in grade 2 (i.e., a parent effect). Present findings demonstrate the importance of maternal warmth in the early school-age years for decreasing subsequent child anxiety.

Diabetes: how to manage cardiovascular risk in secondary prevention patients

Atherosclerotic cardiovascular disease (ASCVD) commonly affects people with type 2 diabetes (T2D). Historically, traditional cardiovascular (CV) risk-lowering therapies in patients with T2D and ASCVD have included antiplatelet agents, blood pressure-lowering therapies, lipid-lowering therapies and healthy lifestyle modifications. In the past decade, multiple antihyperglycaemic agents have emerged as CV risk-lowering therapies in this population as well. This article provides a narrative review on the current non-glycaemic and glycaemic treatment options for CV risk reduction in patients with T2D and ASCVD. The FDA requirement that all new antihyperglycaemic agents undergo cardiovascular outcomes trials has demonstrated increasing evidence to support the role of glucagon-like peptide 1 (GLP1) receptor agonists and sodium–glucose cotransporter 2 (SGLT2) inhibitors as first-line agents for both glycaemic control and CV risk reduction in this population.

Retrospective cohort study of statin prescribing for primary prevention among people living with HIV

Objective

To compare statin prescribing rates between intermediate-risk people living with human immunodeficiency virus (HIV; PLWH) and intermediate-risk patients without a diagnosis of HIV for primary prevention of atherosclerotic cardiovascular disease (ASCVD).

Methods

Retrospective cohort study . Electronic health record data were used to identify a cohort of PLWH aged 40-75 years with a calculated 10-year ASCVD risk between 7.5%-19.9% as determined by the Pooled Cohort Equation (PCE). A matched cohort of primary prevention non-HIV patients was identified. The primary outcome was the proportion of PLWH who were prescribed statin therapy compared to patients who were not living with HIV and were prescribed statin therapy.

Results

81 patients meeting study criteria in the PLWH cohort were matched to 81 non-HIV patients. The proportion of patients prescribed statins was 33.0% and 30.9% in the PLWH and non-HIV cohorts, respectively (p = 0.74).Conclusion and relevance: This study evaluated statin prescribing in PLWH for primary prevention of ASCVD as described in the 2018 AHA/ACC/Multisociety guideline. Rates of statin prescribing were similar, yet overall low, among intermediate-risk primary prevention PLWH compared to those not diagnosed with HIV.

Clinical Pharmacist Outreach to Increase Statin Use for Patients with Cardiovascular Disease in a Safety-Net Healthcare System

BACKGROUND

Statin Therapy for Patients with Cardiovascular Disease (SPC) is a Centers for Medicare & Medicaid Services Star measure added to Medicare Part C (Medicare Advantage) plans in 2019 to incentivize statin use for secondary prevention of cardiovascular disease (CVD). The measure assesses statin dispensing and adherence in patients with atherosclerotic CVD (ASCVD). Clinical pharmacists are well-positioned to affect positively a health system's performance on the SPC measure.

OBJECTIVE

To assess the effect of telephone outreach by clinical pharmacists on moderate- or high-intensity statin prescribing in patients with ASCVD.

METHODS

Patients in managed care health plans who meet the SPC measure criteria and are not currently receiving a moderate- to high-intensity statin therapy were contacted by a clinical pharmacist through telephone outreach. If appropriate, they were prescribed a statin by a clinical pharmacist. The primary outcome measure was the proportion of patients who meet the SPC measure classification and had 1 confirmed prescription fill for a moderate- or high-intensity statin after intervention by a clinical pharmacist.

RESULTS

A total of 84 patients were identified for review and outreach, of whom 35 (41.7%) met the SPC measure criteria. Of these 35 patients, 16 (45.7%) were female and the mean age was 66 years. A total of 22 (62.9%) patients agreed to a statin prescription, and 16 (72.7%) of these patients picked up the prescription within 10 days of prescribing. An additional 4 patients, for a total of 20 (57.1%) of the 35 eligible patients, were eventually dispensed a statin. Healthcare Effectiveness Data and Information Set (HEDIS) vendor data available after the intervention showed a larger SPC measure population than was captured with the health plan's internal report. HEDIS data showed an increase in statin prescribing for patients meeting the SPC measure classification from 24.7% to 56.6% during the study period (P <.001). The mean time spent per patient for chart review and/or outreach by the clinical pharmacist was 27.7 (standard deviation, 9) minutes.

CONCLUSION

These results indicate that clinical pharmacists who conduct a telephonic population health intervention can achieve a high rate of success in initiating a moderate- to high-intensity statin therapy in patients with ASCVD.

Antihypertensive prescribing patterns and hypertension control in females of childbearing age

PURPOSE

The use of angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) to treat hypertension (HTN) during pregnancy presents well-established risks to a developing fetus. A cross-sectional study was conducted to evaluate the current state of antihypertensive prescribing and contraceptive use in females of childbearing age within a large safety-net health system.

METHODS

The retrospective cross-sectional study focused on females aged 18-49 years with a documented diagnosis of HTN. The proportion of patients prescribed an ACE inhibitor or ARB and using a documented form of contraception was calculated. Documented forms of contraception included oral contraceptives, intrauterine devices, injections, implants, and surgical intervention.

RESULTS

A total of 4,187 patients were identified from the HTN registry; after application of exclusion criteria 3,045 patients were included in the study population. The mean age was 39 years (range, 18-49 years). The most frequently prescribed classes of antihypertensive medications were ACE inhibitors and ARBs (one or the other was used by 1,146 patients [37.6%]), followed by thiazide diuretics (n = 710, 23.3%) and calcium channel blockers (n = 599, 19.7%). Of the 1,146 patients prescribed an ACE inhibitor or ARB, 553 (48%) were using a documented form of contraception.

CONCLUSION

Rates of ACE inhibitor or ARB prescribing to females of childbearing age were high despite the teratogenic risks, and fewer than half of patients had documented protection from pregnancy. Provider and patient education and potential creation of best practice alerts in the electronic medical record regarding the risks of using ACE inhibitors and ARBs in females of childbearing age are warranted.

Drugs in Context Editorial: Review of 2020 and what lies ahead in therapeutic interventions

The year 2020 was dominated by the COVID-19 pandemic, bringing with it unprecedented advancements in the fields of healthcare and therapeutic interventions as well as in vaccine and drug development. Nevertheless, several other advancements in various fields of medicine also deserve attention. Herein, the Senior Editors of Drugs in Context provide us with their expert opinion on the events of 2020 and what lies ahead in 2021.

Ertugliflozin in the treatment of type 2 diabetes mellitus

More than 422 million people worldwide have diabetes, with 90–95% having type 2 diabetes (T2D). Glycemic control of T2D has demonstrated reductions in microvascular complications but recent data have demonstrated improvements in macrovascular outcomes with sodium–glucose cotransporter 2 (SGLT2) inhibitors. Ertugliflozin is the most recent SGLT2 inhibitor approved in the USA and Europe for the treatment of T2D. This narrative review aims to present and discuss the efficacy, safety, cardiovascular (CV), and renal outcomes related to the use of ertugliflozin in T2D. Ertugliflozin has been evaluated in eight clinical trials (n=5248) with a focus on glycemic control. These trials have demonstrated improvement in glycosylated hemoglobin (0.6–1%), fasting plasma glucose (30–50 mg/dL), 2-hour postprandial glucose (60–70 mg/dL), decreased body weight (2–3 kg), and lowering of blood pressure (3–5 mmHg) in patients with T2D when ertugliflozin is used as monotherapy or in addition to metformin, sitagliptin, insulin, and/or sulfonylureas. The findings from the VERTIS-CV trial (n=8246) were recently published and demonstrated that ertugliflozin use in patients with T2D and atherosclerotic CV disease is safe but did not demonstrate superiority in the lowering of major CV events compared to placebo. Other SGLT2 inhibitors, such as empagliflozin and canagliflozin, have demonstrated this benefit. The VERTIS-CV trial demonstrated that the use of ertugliflozin led to a decrease in the number of hospitalizations for heart failure and this lends further support that this benefit is a class effect of SGLT2 inhibitors.

Bempedoic acid for the treatment of dyslipidemia

Cardiovascular disease (CVD) is the leading cause of death worldwide and one key factor associated with the increased CVD risk is dyslipidemia. Statin therapy remains the first-line treatment to manage dyslipidemia, yet many patients do not achieve optimal low-density lipoprotein-cholesterol (LDL-C) levels even after taking moderate- or high-intensity statins; therefore, additional, non-statin therapy is often needed. Bempedoic acid is a prodrug that, once activated, decreases LDL-C levels by the inhibition of adenosine triphosphate citrate lyase in the liver. Five clinical trials have demonstrated the safety and efficacy of bempedoic acid and the bempedoic acid/ezetimibe combination in lowering LDL-C in patients with atherosclerotic CVD and heterozygous familial hypercholesterolemia and also in high-risk primary prevention, and statin-intolerant patients. Bempedoic acid has been demonstrated to lower LDL-C levels by 15-25% in clinical trials and up to 38% when combined with ezetimibe. In 2020, the FDA approved bempedoic acid. Furthermore, the combination of bempedoic acid with ezetimibe is FDA approved for the treatment of adults with heterozygous familial hypercholesterolemia or established atherosclerotic CVD who require additional LDL-C lowering after maximally tolerated statin therapy. The ongoing CLEAR OUTCOMES trial aims to evaluate whether bempedoic acid can reduce cardiovascular events in patients with statin intolerance and results will be available in the next 3 years. This outcomes trial will be pivotal for determining the role of bempedoic acid in the non-statin lipid-lowering armamentarium.

Evaluation of a Pharmacist-Led Intervention to Improve Statin Use in Persons with Diabetes

BACKGROUND

The Statin Use in Persons with Diabetes (SUPD) measure, developed and endorsed by the Pharmacy Quality Alliance and National Quality Forum, has been adopted by the Centers for Medicare & Medicaid Services as part of the star rating measure set. It was added as a display measure in 2015 and, as of 2019, has become a star measure. Clinical pharmacy specialists (CPS) embedded in the patient-centered medical home (PCMH) are well positioned to review and recommend statin therapy for patients with diabetes in order to improve patient care and health plan performance.

OBJECTIVE

To improve rates of statin prescribing and performance on the SUPD measure in the Denver Health Medical Plan (DHMP) population with diabetes by creating a CPS-led intervention to initiate statin prescriptions in eligible patients.

METHODS

Between February 1, 2018, and December 31, 2018, DHMP patients who met SUPD measure criteria (aged ≥ 40 and ≤ 75 years, dispensing events for at least 2 diabetes mellitus medication fills, and no statin prescribed) were identified by the health plan chart review and contacted by CPS as appropriate. For patients eligible and agreeable to statin therapy, the CPS initiated the statin prescription. Descriptive statistics were used to summarize outreach and statin prescribing data. Prescription drug event data were also collected from the health plan to verify SUPD measure performance.

RESULTS

At the start of 2018, DHMP's performance on the SUPD measure was 65.7% (Medicare Advantage Part D national average was 68.5%). Of the 326 patients whose charts were reviewed and who were contacted, 275 (84.4%) were eligible for statin initiation, and of these, 115 (41.8%) were prescribed statin therapy. The increase in statin prescribing and dispensing increased DHMP's performance on the SUPD measure to 87.1% at the end of 2018, which correlates with a 5-star rating based on the 2019 cut points.

CONCLUSIONS

CPS embedded in the PCMH setting are well positioned to participate in and positively affect population health initiatives such as the SUPD measure. Appropriate prescribing of statin therapy by CPS for patients included in the SUPD measure ensures that they are on key medication therapy for mitigating atherosclerotic cardiovascular disease and may improve a health plan's Medicare star rating.

DISCLOSURES

This was an unfunded, investigator-initiated project. Anderson owns stock in Merck & Co. All other authors have no conflicts of interest to disclose.

Oral semaglutide in type 2 diabetes

BACKGROUND

Previously, the only available glucagon-like peptide-1 receptor agonists (GLP-1 RA) were injectable. Approval of oral semaglutide (Rybelsus®) represents the first orally available GLP-1 RA.

OBJECTIVE

To review the literature and describe pharmacologic, pharmacokinetic, and pharmacodynamics properties; clinical safety; and efficacy of oral semaglutide, a newly approved oral GLP-1 RA.

METHODS

A MEDLINE (1995-October 2019) and ClinicalTrials.gov search was conducted using the terms oral semaglutide, semaglutide, PIONEER, and a combination of those terms. Reference citations from publications identified were also reviewed. All English-language studies, including abstracts, evaluating oral semaglutide use in humans were included in this review.

CONCLUSIONS

The approval of oral semaglutide (Rybelsus®) represents a paradigm shift in the management of T2D as this is the first FDA-approved oral GLP-1 RA. Oral semaglutide may be an attractive option for patients with T2D who require improved glycemic control, would like to lose weight, and who are not interested in injectable therapy. However, the lack of positive cardiovascular (CV) and renal data are significant limitations to its use.

The Influence of Social Support and Social Integration Factors on Return to Work Outcomes for Individuals with Work-Related Injuries: A Systematic Review

Purpose In occupational rehabilitation, the biopsychosocial model endorses the role of social factors in worker recovery. We conducted a systematic review to explore three questions examining the role of social support for the return-to-work (RTW) of individuals with work-related injury: (1) What are the worker-identified social barriers and facilitators in RTW; (2) What is the relationship between social factors and RTW; and (3) What is the effectiveness of social interventions for RTW. Methods Systematic searches of six databases were conducted for each research question. These identified 11 studies meeting inclusion criteria for Research Question 1, and 12 studies for Research Question 2. No studies were identified that met inclusion criteria for Research Question 3. A narrative synthesis approach was used to analyse the included studies. Results Research Question 1 identified five themes in social barriers and facilitators to RTW, including contact/communication, person-centred approaches, mutual trust, reaction to injury, and social relationships. Research Question 2 identified moderate support for reaction to injury and social integration/functioning as predictors of RTW and weak evidence for co-worker support. Four studies reported significant associations between social factors and RTW, six reported mixed findings with at least one significant social predictor, and two found no significant relationships. However, conclusions were limited by the inconsistency in measurement of social factors. Conclusions Our findings indicate that social support and integration may influence RTW following work-related injury, and highlights the need for further systematic examination of social factors in the field of occupational rehabilitation.

Implementation of a Pharmacist-Led Diabetes Management Protocol

BACKGROUND

Little data exist regarding how pharmacist-led collaborative drug therapy management protocols are implemented in health systems. Barriers to collaborative drug therapy management protocol implementation exist, but they can be overcome by effective protocol education and communication, allowing pharmacists to manage more patients with chronic disease states, thereby enhancing quality health outcomes for patients and reducing health resource utilization.

OBJECTIVE

To determine the preferred method of provider education regarding the implementation of a pharmacist-led type 2 diabetes collaborative drug therapy management protocol, and to assess pharmacist and provider satisfaction with the protocol implementation.

METHODS

This single-center, prospective cohort study included pharmacists practicing within a pharmacist-led type 2 diabetes collaborative drug therapy management protocol, as well as providers practicing at 4 primary care clinics within a health system. All providers received an e-mail regarding education about the protocol. In addition, providers at 2 of the clinics received education about the protocol at a provider meeting, and providers at the other 2 clinics received a personalized provider report card. The personalized provider report card identified patients within the provider's panel who met criteria for referral to a pharmacist under the new protocol. The referred patients were tracked for 2 months, and provider and pharmacist satisfaction with the protocol were assessed.

RESULTS

A total of 54 patients were referred for pharmacist management per the protocol. The majority (89%) of patients were referred by providers who received a personalized provider report card. Nearly all (96%) of the providers were satisfied with the protocol-driven services, and most (67%) pharmacists were satisfied with their role in managing patients with type 2 diabetes under the collaborative drug therapy management protocol.

CONCLUSION

The majority of patients with type 2 diabetes who were referred for pharmacist management per the protocol were referred by providers who received personalized provider report cards. Provider and pharmacist satisfaction with the new pharmacist-led protocol was high.

Sacubitril/valsartan: evaluation of safety and efficacy as an antihypertensive treatment

Hypertension (HTN) is a common disease state associated with extensive morbidity and mortality worldwide. It is often difficult for patients with HTN to achieve and maintain a goal blood pressure (BP), despite there being many effective treatment options available. Sacubitril/valsartan is a first-in-class angiotensin receptor neprilysin inhibitor (ARNI) that has garnered approval by the US Food and Drug Administration and the European Medicines Agency as a first-line treatment for heart failure with reduced ejection fraction. During clinical trials for heart failure as well as in independent trials for HTN, sacubitril/valsartan has demonstrated safety and efficacy when it comes to BP lowering, making it a promising antihypertensive agent. Most trials of sacubitril/valsartan were 8 to 12 weeks in length and demonstrated a clinically relevant BP lowering that was frequently more significant than its comparators. While more data are needed to confirm its role as an antihypertensive agent, the data available are promising and it is anticipated that sacubitril/valsartan will gain an indication of HTN.

Predicting Risky Sexual Behavior: the Unique and Interactive Roles of Childhood Conduct Disorder Symptoms and Callous-Unemotional Traits

Conduct disorder (CD) symptoms and callous-unemotional (CU) traits have been shown to be uniquely associated with risky sexual behavior (RSB) in adolescence and early adulthood, yet their interactive role in predicting RSB remains largely unknown. This study aimed to investigate the predictive value of CD symptoms and CU traits, as well as their interaction, on several RSB outcomes in adolescence and early adulthood. A total of 683 participants (41.7 % female, 47.4 % African American) were followed annually and self-reported age of first sexual intercourse, frequency of condom use, pregnancy, contraction of sexually transmitted infections, and engagement in sexual solicitation from grade 7 to 2-years post-high school. CD symptoms predicted age of first sexual intercourse, condom use, and sexual solicitation. CU traits predicted age of first sexual intercourse and pregnancy. Their interaction predicted a composite score of these RSBs such that CD symptoms positively predicted the composite score among those with high levels of CU traits but not among those with low levels of CU traits. The current findings provide information regarding the importance of both CD symptoms and CU traits in understanding adolescent and early adulthood RSB, as well as the benefits of examining multiple RSB outcomes during this developmental period. These findings have implications for the development and implementation of preventive efforts to target these risky behaviors among adolescents and young adults.

Reliability and concurrent validity of the iPhone® Compass application to measure thoracic rotation range of motion (ROM) in healthy participants

Background

Several water-based sports (swimming, surfing and stand up paddle boarding) require adequate thoracic mobility (specifically rotation) in order to perform the appropriate activity requirements. The measurement of thoracic spine rotation is problematic for clinicians due to a lack of convenient and reliable measurement techniques. More recently, smartphones have been used to quantify movement in various joints in the body; however, there appears to be a paucity of research using smartphones to assess thoracic spine movement. Therefore, the aim of this study is to determine the reliability (intra and inter rater) and validity of the iPhone^® app (Compass) when assessing thoracic spine rotation ROM in healthy individuals.

Methods

A total of thirty participants were recruited for this study. Thoracic spine rotation ROM was measured using both the current clinical gold standard, a universal goniometer (UG) and the Smart Phone Compass app. Intra-rater and inter-rater reliability was determined with a Intraclass Correlation Coefficient (ICC) and associated 95% confidence intervals (CI). Validation of the Compass app in comparison to the UG was measured using Pearson’s correlation coefficient and levels of agreement were identified with Bland–Altman plots and 95% limits of agreement.

Results

Both the UG and Compass app measurements both had excellent reproducibility for intra-rater (ICC 0.94–0.98) and inter-rater reliability (ICC 0.72–0.89). However, the Compass app measurements had higher intra-rater reliability (ICC = 0.96 − 0.98; 95% CI [0.93–0.99]; vs. ICC = 0.94 − 0.98; 95% CI [0.88–0.99]) and inter-rater reliability (ICC = 0.87 − 0.89; 95% CI [0.74–0.95] vs. ICC = 0.72 − 0.82; 95% CI [0.21–0.94]). A strong and significant correlation was found between the UG and the Compass app, demonstrating good concurrent validity (r = 0.835, p < 0.001). Levels of agreement between the two devices were 24.8° (LoA –9.5°, +15.3°). The UG was found to consistently measure higher values than the compass app (mean difference 2.8°, P < 0.001).

Conclusion

This study reveals that the iPhone^® app (Compass) is a reliable tool for measuring thoracic spine rotation which produces greater reproducibility of measurements both within and between raters than a UG. As a significant positive correlation exists between the Compass app and UG, this supports the use of either device in clinical practice as a reliable and valid tool to measure thoracic rotation. Considering the levels of agreement are clinically unacceptable, the devices should not be used interchangeably for initial and follow up measurements.

A Review of the Role of the Pharmacist in Heart Failure Transition of Care

This article reviews current literature on the role of pharmacists in the transition of care (TOC) for patients with heart failure (HF) and the impact of their contributions on therapeutic and economic outcomes. Optimizing the TOC for patients with HF from the hospital to the community/home is crucial for improving outcomes and decreasing high rates of hospital readmissions, which are associated with increased morbidity, mortality, and costs. A multidisciplinary team approach to the management of patients with HF facilitates the transition from the hospital to the ambulatory care setting, allowing for the consideration of medical, pharmacological, and lifestyle variables that impact the care of individual patients. Pharmacist participation on both inpatient and outpatient teams can provide a variety of services that have been shown to reduce hospital readmission rates and benefit patient management and treatment. These include medication reconciliation, patient education, medication dosage titration and adjustment, patient monitoring, development of disease management pathways, promotion of medication adherence, and postdischarge follow-up. In addition, as new pharmacologic treatments for HF become available, pharmacists can raise awareness of optimal drug use by maximizing education related to efficacy (e.g., adherence) and safety (e.g., potential side effects and drug interactions). Improving understanding of HF and its treatment will enable increased pharmacist involvement in the TOC that should lead to improved outcomes and reduced healthcare costs.

FUNDING

Novartis.

Phase I/II trial of pembrolizumab in combination with binimetinib in unresectable locally advanced or metastatic triple negative breast cancer

TPS17

Background: Emerging studies suggest that breast cancer, particularly triple negative breast cancer (TNBC), may be sensitive to immunotherapy. However, the response rate of single agent immune checkpoint blockade agent in TNBC is rather low. Previous genomic study in residual tumor after neoadjuvant chemotherapy showed inverse correlations between MEK activation signature and the amount of tumor infiltrating lymphocytes (TILs) in residual disease samples as well as poor outcome. Preclinical study also showed that the combination of MEK inhibitor and anti-PD-L1 antibody in mouse model can eradicate TNBC tumors. Methods: This is a single arm, Phase I/II trial of Pembrolizumab (P) in combination with Binimetinib (B) in patients with unresectable locally advanced or metastatic TNBC. This trial is currently opened for accrual at Mayo Clinic in Florida and Minnesota. Patients with TNBC defined as ER ≤ 10% and PR ≤ 10% who received ≤ 3 prior lines with measurable disease will be enrolled. The primary objective of the Phase I part is to determine the maximum tolerated dose of B in combination with P and for the Phase II part is objective response rate (ORR) by RECIST criteria. The secondary endpoints include ORR by irRECIST, progression free survival, and overall survival. The total sample size is 15-38 patients with 6-12 patients in Phase I with 2 dose levels and 9-26 patients in Phase II. Simon’s Two-Stage Optimal Design is used to test the null hypothesis that this two-drug combination has an ORR of at most 15% vs. the alternative hypothesis that it has an ORR of at least 35%. Patients will receive single agent B for 2 weeks prior to starting P. A mandatory biopsy will be performed before starting B and an optional biopsy will be performed after 2 weeks of B. Tumor tissue will be evaluated for the amount and phenotypes of TILs, PD-L1 expression, and gene expression analysis using PanCancer Immune Profiling Panel, and PDJ amplification. Peripheral blood will be evaluated for circulating immunoregulatory cells, cytokine profiling, circulating tumor cells (CTCs), as well as p-ERK and PD-L1 expression on CTCs. Clinical trial information: NCT03106415.

Switching basal insulins in type 2 diabetes: practical recommendations for health care providers

Basal insulin remains the mainstay of treatment of type 2 diabetes when diet changes and exercise in combination with oral drugs and other injectable agents are not sufficient to control hyperglycemia. Insulin therapy should be individualized, and several factors influence the choice of basal insulin; these include pharmacological properties, patient preferences, and lifestyle, as well as health insurance plan formularies. The recent availability of basal insulin formulations with longer durations of action has provided further dosing flexibility; however, patients may need to switch agents throughout therapy for a variety of personal, clinical, or economic reasons. Although a unit-to-unit switching approach is usually recommended, this conversion strategy may not be appropriate for all patients and types of insulin. Glycemic control and risk of hypoglycemia must be closely monitored by health care providers during the switching process. In addition, individual changes in care and formulary coverage need to be adequately addressed in order to enable a smooth transition with optimal outcomes.

Abstract 076: Factors Associated With Home Blood Pressure Monitoring Among US Adults: The National Health and Nutrition Examination Survey (NHANES), 2013-2014

Introduction: National prevalence data on home blood pressure monitoring (HBPM) has previously been reported from 2009-2010, but no recent data has been reported.

Methods: This report is based on national-level, cross-sectional data for noninstitutionalized US adults aged ≥18 years (n = 6,113 participants) from the National Health and Nutrition Examination Survey (NHANES), 2013-2014.

Results: Overall, 25.5% (1560 of 6113) of the adults engaged in HBPM monitoring in the 2013-2014 survey year. This is an increase from the previous NHANES 2009-2010 analysis reporting a 21.7% (1302 of 6001) rate. The frequency of HBPM increased with higher age, higher education level, having a partner, hypertensive, hypertensive aware, and hypertensive treated. Both SBP and DBP were higher in the HBPM group and were both statistically significant. The groups of hypertensive, hypertensive-aware, and hypertensive-treated patients all showed higher rates of HBPM use than nonuse. The frequency of HBPM monitoring in the categories of less than monthly, monthly, and weekly was reported at rates of 7.8% (476 of 6113), 6.6% (401 of 6113), and 11.2% (683 of 6113), respectively. These reported rates are consistent and slightly increased in the weekly HBPM reported use compared with the NHANEs 2009-2010 analysis (7.2% [432 of 6001], 6.6% [396 of 6001], and 7.9% [474 of 6001), respectively). Adjusting for covariables, those who were aware of, treated for, and had known hypertension were more likely to have a higher frequency of HBPM than the reference: unaware, untreated, and no known hypertension (odds ratio (OR) = 1.98; OR = 2.13; and OR = 1.64, respectively). Individuals with less than a high school diploma and having no partner were less likely to perform HBPM than the reference: high school graduate or greater and having a partner (OR = 0.73; OR = 0.65, respectively).

Conclusions: Approximately 21.0% (1084 of 6113) of adults engaged in monthly or more frequent HBPM which is an increase from the reported 14.5%(870 of 6001) rate in the 2009-2010 analysis. Having hypertension, being aware of hypertension, and being treated for hypertension were associated with an increased frequency of HBPM. Having no partner and less than a high school diploma were associated with lower frequency of HBPM.

Antihyperglycemic Medications and Cardiovascular Risk Reduction

Cardiovascular disease (CVD) remains a leading cause of death in patients with type 2 diabetes (T2D). In addition to glycemic control, a major focus of diabetes treatment involves cardiovascular (CV) risk reduction. In 2008, the US Food and Drug Administration (FDA) instituted a new requirement that new drugs developed and studied for the treatment of T2D must undergo CV safety testing. Since the advent of this new policy, canagliflozin, empagliflozin, liraglutide and semaglutide have demonstrated superior CV event reduction - via a composite of reduction in CV death, nonfatal myocardial infarction (MI), and nonfatal stroke - compared with placebo in patients with T2D and existing CVD, or at high risk of CVD. Multiple studies are underway to evaluate the CV outcomes of other antihyperglycemic agents. In a time when there are numerous drugs in the T2D armamentarium, positive CV outcomes data influence drug selection and aids practitioners in making more individualised therapeutic recommendations for their patients.

Basal Insulin Use With GLP-1 Receptor Agonists

IN BRIEF The combination of basal insulin and a glucagon-like peptide 1 receptor agonist is becoming increasingly common and offers several potential benefits to patients with type 2 diabetes. Clinical studies have demonstrated improved glycemic control and low risks of hypoglycemia and weight gain with the combination, which provides a safe and effective alternative to basal-bolus insulin with less treatment burden. Fixed-ratio combination products that administer both agents in a single injection are in the pipeline and will offer additional options for clinicians and patients. This review focuses on the rationale for, clinical evidence on, and implications of using this combination of therapies in the treatment of type 2 diabetes.

Neutrophil apoptosis is delayed in an equine model of colitis: Implications for the development of systemic inflammatory response syndrome

BACKGROUND

Horses that develop colitis invariably exhibit signs of a systemic inflammatory response syndrome (SIRS). A significant contributor to the development of SIRS in human subjects is delayed neutrophil apoptosis, but this has not been specifically studied in horses.

OBJECTIVES

To determine the occurrence of ex vivo neutrophil apoptosis and its contribution to the development of SIRS in an equine colitis model.

STUDY DESIGN

Experiment using a colitis model.

METHODS

Neutrophils were isolated before and after the induction of colitis using an oligofructose overdose model, placed into culture for 12 h or 24 h with or without lipopolysaccharide (LPS) at various concentrations, and assessed for the occurrence of apoptosis using Annexin V and propidium iodide staining with flow cytometric quantification. Levels of caspase-3, -8 and -9 activity were measured after 12 h of incubation in neutrophil lysates.

RESULTS

Ex vivo neutrophil apoptosis was significantly delayed in neutrophils isolated after the induction of colitis (12-h incubation: P = 0.004; 24-h incubation: P = 0.003) with concomitant reductions in caspase-3, -8 and -9 activity (caspase-3: P = 0.004; caspase-8: P = 0.02; caspase-9: P = 0.02). Neutrophils isolated after the induction of colitis were refractory to LPS-delayed apoptosis. Neutrophil apoptosis was delayed with increasing cell concentration in vitro.

MAIN LIMITATIONS

The main limitation of the study is the that the exact mechanism for delayed neutrophil apoptosis following the induction of colitis was not fully elucidated.

CONCLUSIONS

The data show that neutrophil apoptosis is delayed in horses following the induction of colitis as a result of interference with the intrinsic and extrinsic apoptotic pathways, which may contribute to the development of equine SIRS. Concurrent development of neutrophilia may contribute to a prolonged neutrophil lifespan through a concentration-dependent delay in apoptosis.

Lixisenatide in type 2 diabetes: latest evidence and clinical usefulness

Type 2 diabetes (T2D) is a highly prevalent disorder that affects millions of people worldwide. The hallmark of T2D is hyperglycemia and, while many treatment modalities exist, achieving and maintaining glycemic control can be challenging. Glucagon-like peptide-1 (GLP-1) receptor agonists (RAs) are an appealing treatment option as they improve glycemic control, reduce weight, and limit the risk of hypoglycemia. Lixisenatide is a once-daily GLP-1 RA that has been evaluated in the GetGoal clinical trial program and has demonstrated efficacy and tolerability across a spectrum of patients. The feature that most distinguishes lixisenatide from other GLP-1 RAs is its ability to substantially reduce postprandial glucose (PPG) for the meal immediately following injection. Because of its positive effects on PPG, lixisenatide is being considered as a replacement for prandial insulin, and a fixed dose combination product containing lixisenatide and basal insulin is in development. Lixisenatide is a promising new addition to the antidiabetic armamentarium, but due to the lack of real-world experience with the drug, its exact place in therapy is unknown.

Effects of Medical Marijuana on Migraine Headache Frequency in an Adult Population

STUDY OBJECTIVE

No clinical trials are currently available that demonstrate the effects of marijuana on patients with migraine headache; however, the potential effects of cannabinoids on serotonin in the central nervous system indicate that marijuana may be a therapeutic alternative. Thus, the objective of this study was to describe the effects of medical marijuana on the monthly frequency of migraine headache.

DESIGN

Retrospective chart review.

SETTING

Two medical marijuana specialty clinics in Colorado.

PATIENTS

One hundred twenty-one adults with the primary diagnosis of migraine headache who were recommended migraine treatment or prophylaxis with medical marijuana by a physician, between January 2010 and September 2014, and had at least one follow-up visit.

MEASUREMENTS AND RESULTS

The primary outcome was number of migraine headaches per month with medical marijuana use. Secondary outcomes were the type and dose of medical marijuana used, previous and adjunctive migraine therapies, and patient-reported effects. Migraine headache frequency decreased from 10.4 to 4.6 headaches per month (p<0.0001) with the use of medical marijuana. Most patients used more than one form of marijuana and used it daily for prevention of migraine headache. Positive effects were reported in 48 patients (39.7%), with the most common effects reported being prevention of migraine headache with decreased frequency of migraine headache (24 patients [19.8%]) and aborted migraine headache (14 patients [11.6%]). Inhaled forms of marijuana were commonly used for acute migraine treatment and were reported to abort migraine headache. Negative effects were reported in 14 patients (11.6%); the most common effects were somnolence (2 patients [1.7%]) and difficulty controlling the effects of marijuana related to timing and intensity of the dose (2 patients [1.7%]), which were experienced only in patients using edible marijuana. Edible marijuana was also reported to cause more negative effects compared with other forms.

CONCLUSION

The frequency of migraine headache was decreased with medical marijuana use. Prospective studies should be conducted to explore a cause-and-effect relationship and the use of different strains, formulations, and doses of marijuana to better understand the effects of medical marijuana on migraine headache treatment and prophylaxis.

Novel class of medications, orexin receptor antagonists, in the treatment of insomnia - critical appraisal of suvorexant

Insomnia, a highly prevalent disorder, can be detrimental to patients' overall health and worsen existing comorbidities. Patients may have acute episodes of insomnia related to a traumatic event, but more commonly insomnia occurs chronically. While proper sleep hygiene and behavioral therapy play important roles in the nonpharmacologic management of short-term and chronic insomnia, medications may also be required. Historically, insomnia has been treated with agents such as benzodiazepines, nonbenzodiazepine receptor agonists, and melatonin agonists. Dual orexin receptor antagonists represent a new class of medications for the treatment of insomnia, which block the binding of wakefulness-promoting neuropeptides orexin A and orexin B to their respective receptor sites. Suvorexant (Belsomra) is the first dual orexin receptor antagonist to be approved in the US and Japan and has demonstrated efficacy in decreasing time to sleep onset and increasing total sleep time. Its unique mechanism of action, data to support efficacy and safety over 12 months of use, and relative lack of withdrawal effects when discontinued may represent an alternative for patients with chronic insomnia who cannot tolerate or do not receive benefit from more traditional sleep agents. Suvorexant is effective and well tolerated, but precautions exist for certain patient populations, including females, obese patients, and those with respiratory disease. Suvorexant has only been studied vs placebo, and hence it is unknown how it directly compares with other medications approved by the US Food and Drug Administration for insomnia. Suvorexant is not likely to replace benzodiazepines or nonbenzodiazepine receptor antagonists as a first-line sleep agent but does represent a novel option for the treatment of patients with chronic insomnia.

Suvorexant in insomnia: efficacy, safety and place in therapy

Insomnia is a highly prevalent disorder that can occur in conjunction with other medical or psychiatric conditions or can occur in the absence of a coexisting disorder. Regardless, treatment of insomnia is beneficial to the patient and may benefit comorbidities if they exist. Nonpharmacologic modalities such as sleep hygiene and stimulus controls are important mainstays of insomnia therapy, but may not be sufficient to treat the disorder. Dual orexin receptor antagonists (DORAs) are a new class of insomnia medication that target wakefulness-promoting neuropeptides to regulate the sleep-wake cycle. Suvorexant is the first DORA to be approved and has demonstrated efficacy at decreasing both time to sleep onset and increasing total sleep time compared with placebo. Suvorexant has a novel mechanism of action and may represent an alternative for patients who cannot tolerate or do not receive benefit from traditional sleep agents. Suvorexant is generally effective and well tolerated, but has not been compared head to head with traditional sleep agents and being only newly available, lacks a longer-term 'real-world' experience base.

Abstract 304: Developing a Patient Registry for Atrial Fibrillation to Improve The Quality of Stroke Prevention in a Safety Net Institution

Background: Anticoagulant-based prophylaxis in atrial fibrillation patients at high-risk for stroke remains underutilized in clinical practice despite extensive literature supporting its benefits. The recent 2014 AHA/ACC/HRS Atrial Fibrillation Guidelines emphasize risk stratification to target anticoagulation to those who would derive the most benefit. Rapid guideline implementation could be achieved through patient registries and decision support that provide actionable information at the point of care. Our objective is to risk-stratify primary care patients with atrial fibrillation at Denver Health (DH), an integrated safety net health system, and to characterize patterns of anticoagulation use and non-use as the first phase of a quality improvement initiative that includes development of a disease registry.

Methods: We identified patients diagnosed with atrial fibrillation who made one or more visits over a two-year period to a primary care site at DH. We utilized the CHA2DS2VASc score to stratify patients as low-risk (score = 0 or 1 if female gender was the sole risk factor), intermediate-risk (score = 1), or high-risk (score = 2+) of stroke. We examined the use of anticoagulant therapy within each stratum. For patients at high-risk, we compared characteristics between those who were on any anticoagulant and those who were not. We examined differences in age, gender, payer, HAS-BLED score, and modifiable factors that contribute to the HAS-BLED score. HAS-BLED score was calculated using ICD9 codes, vital signs, and laboratory values drawn from electronic medical record data.

Results: The study population of 867 patients had a median age of 64 years (interquartile range: 56-73) and 373 (43%) were women. Of the 867 patients, 168 (19.4%) were uninsured, 227 (26.2%) were covered by Medicaid, and 425 (49%) by Medicare. CHA2DS2VASc score-based stratification indicated 59 (6.8%), 71 (8.2%), and 737 (85%) patients were at low, intermediate, and high-risk, respectively. Of the low-risk patients, 13 (22%) were on anticoagulants, despite guidelines recommending no therapy for these patients. Anticoagulation rates among the intermediate and high-risk strata were 60.6% (43 of 71) and 64.5% (475 of 737), respectively. Among high-risk patients, those not on anticoagulation were more likely to have uncontrolled hypertension, abnormal liver function, or were on medications that predispose to bleeding. There were no significant differences in the proportion of patients with a HAS-BLED score of 3+ among those high-risk patients receiving anticoagulation and those not.

Conclusions: A baseline assessment of stroke prophylaxis among atrial fibrillation patients in a safety net health system demonstrates nonguideline-concordant anticoagulation use among low-risk patients and suboptimal anticoagulation use among high-risk patients, patterns that could not be explained by HAS-BLED score.

Characterization of diastolic dysfunction heart failure following an acute hospitalization for heart failure in an urban, underserved population

OBJECTIVES

The aim of this retrospective study was to describe demographic and clinical characteristics of patients with diastolic dysfunction heart failure (DHF) in a safety-net institution.

METHODS

Descriptive statistics were used to summarize characteristics for adults with DHF hospitalized for acute decompensated heart failure (ADHF) between 1 January 2009 and 30 June 2010.

RESULTS

Of 483 patients with an ADHF-related admission, only 83 (17.2%) had pure DHF. Mean age was 59.6 ± 13.1 years old, with nearly equal proportions of male and female patients. Hypertension (89.2%), coronary artery disease (74.7%), and diabetes (63.9%) comorbidities were most common. Diuretics (91.6%), angiotensin converting enzyme inhibitors or angiotensin receptor blockers (69.9%), and β blockers (60.3%) were most frequently prescribed on discharge.

CONCLUSION

In our population, DHF is more prevalent in younger patients of any ethnicity, especially Hispanic/Latino and black ethnicities, compared with nationwide estimates. Our patients with DHF had higher ejection fractions and were prescribed higher rates of traditional heart failure medications.

Dapagliflozin efficacy and safety: a perspective review

Type 2 diabetes mellitus is a prevalent, progressive disease with a need for innovative therapeutic agents to continue to advance disease management. Dapagliflozin is the second agent in a new class of oral antihyperglycemic drugs: sodium-glucose cotransporter 2 (SGLT2) inhibitors. SGLT2 is responsible for the majority of renal glucose reuptake; inhibition of the cotransporter allows for increased renal glucose excretion that consequently leads to reduced plasma glucose levels. Because this mechanism does not require the action of insulin, dapagliflozin rarely causes hypoglycemia and is effective in patients both early and late in the course of their disease. Studies of dapagliflozin have demonstrated efficacy both as monotherapy and in combination with oral antihyperglycemic agents and insulin. Dapagliflozin has been shown to decrease hemoglobin A1c (HbA1c) values 6 mmol/mol (0.5%) to 8 mmol/mol (0.7%). The most common adverse reactions observed with dapagliflozin in clinical trials were female genital mycotic infections, urinary tract infections, and nasopharyngitis. Dapagliflozin is a new oral agent for type 2 diabetes with short-term efficacy similar to dipeptidyl peptidase 4 inhibitors; its long-term safety and efficacy are unknown.

Evaluation of Aspirin Use in Patients With Diabetes Receiving Care in Community Health

Background: The American Diabetes Association (ADA) recommends low-dose aspirin therapy as a primary prevention strategy in patients with type 1 or type 2 diabetes mellitus (DM) at increased cardiovascular risk. However, not all patients who are indicated are taking aspirin therapy, and it is not routinely documented in the electronic health record (EHR). Objective: To determine frequencies of appropriate aspirin use and documentation in the EHR in adult patients with DM. Methods: Adult patients with DM were randomized and contacted for participation in a telephonic survey between January and October 2013. Patients who consented were administered a standardized oral telephone survey regarding aspirin use. Patient demographics, current medications, allergies, past medical history, and pertinent laboratory values were collected. Patients were then stratified by the ADA-defined indication for aspirin. The primary outcomes were rates of appropriate aspirin use and documentation of aspirin therapy in the EHR. Results: Investigators contacted 276 patients for inclusion. Of the 81 patients surveyed, 74% were indicated for aspirin therapy. Nearly all (92.3%) patients reporting aspirin use were indicated for aspirin therapy compared with only 57.1% of patients who did not report aspirin but were indicated ( P = 0.0003). Alternatively, 96.7% of patients with aspirin use documented in their EHR were indicated for aspirin therapy compared with only 60.8% of patients who did not have aspirin use documented in the EHR but had an indication ( P = 0.0002). Approximately 20% of the patients indicated for and reporting aspirin use did not have aspirin documented in their EHR. Conclusions: Aspirin use in patients with DM who are indicated for therapy is significantly underutilized and underdocumented.

Characterization of diabetes risk factors in patients prescribed chronic statin therapy

OBJECTIVE

Determine the incidence of major diabetes risk factors over time in patients prescribed chronic statin therapy.

METHODS

Retrospective observational chart review of adult patients without diabetes in primary care who initiated statin therapy between 2005 and 2010. Presence of diabetes risk factors were determined 1 year prior to statin initiation and continued up to a maximum of 7 years. Diabetes risk factors included impaired fasting glucose, body mass index (BMI) ≥30 kg/m(2), hemoglobin A1c >6% and metabolic syndrome. Descriptive statistics were used to describe the incidence of diabetes risk factors over time.

RESULTS

A total of 98 patients met study criteria; mean age was 57 ± 13 years, 43% were men and 71% self-identified as Caucasian/white. Mean baseline values were A1c of 5.97%, fasting glucose of 104 mg/dl and BMI of 28 kg/m(2). There were zero diabetes risk factors over time in 54% ± 7% of patients. The incidence over time of 1 risk factor was 25 ± 9%, 2 risk factors was 17 ± 5% and 3 risk factors was 3 ± 2%. A total of 12 patients were diagnosed with type 2 diabetes during the course of the study period.

CONCLUSION

The incidence of diabetes risk factors did not change over time in an ambulatory adult population prescribed chronic statin therapy. Larger population studies assessing the incidence of and change in diabetes risk factors in patients on chronic statin therapy may help assess the association between statin therapy and presence of such risk factors.

A founder mutation in the TCIRG1 gene causes osteopetrosis in the Ashkenazi Jewish population

Osteopetrosis is a rare and heterogeneous genetic disorder characterized by dense bone mass that is a consequence of defective osteoclast function and/or development. Autosomal recessive osteopetrosis (ARO) is the most severe form and is often fatal within the first years of life; early hematopoietic stem cell transplant (HSCT) remains the only curative treatment for ARO. The majority of the ARO-causing mutations are located in the TCIRG1 gene. We report here the identification and characterization of an A to T transversion in the fourth base of the intron 2 donor splice site (c.117+4A→T) in TCIRG1, a mutation not previously seen in the Ashkenazi Jewish (AJ) population. Analysis of a random sample of individuals of AJ descent revealed a carrier frequency of approximately 1 in 350. Genotyping of five loci adjacent to the c.117+4A→T-containing TCIRG1 allele revealed that the presence of this mutation in the AJ population is due to a single founder. The identification of this mutation will enable population carrier testing and will facilitate the identification and treatment of individuals homozygous for this mutation.

Once-weekly albiglutide in the management of type 2 diabetes: patient considerations

This review describes the pharmacologic, pharmacokinetic, and pharmacodynamic properties of albiglutide, as well as its clinical efficacy and safety. Albiglutide is a novel, once-weekly, injectable glucagon-like peptide-1 receptor agonist for the treatment of type 2 diabetes. The European Commission recently granted marketing authorization for the drug in the European Union and on April 15, 2014, the US Food and Drug Administration approved albiglutide (Tanzeum™ [GlaxoSmithKline LLC, Wilmington, DE, USA]) to improve glycemic control in adults with type 2 diabetes. Albiglutide has been studied in Phase I, II, and III clinical trials. In the Phase III clinical trials, known as the Harmony series, weekly dosing of albiglutide demonstrated reductions in fasting plasma glucose, postprandial plasma glucose, and glycated hemoglobin, and was associated with weight loss. In all phases of the clinical trials, albiglutide administered once weekly showed a safety and tolerability profile similar to that of placebo, with mild gastrointestinal-related complaints and injection site erythema being the most commonly encountered adverse effects. Compared with pioglitazone and liraglutide, albiglutide has been shown to be clinically less effective. However, it offers the benefit of weight loss that pioglitazone does not, with fewer gastrointestinal side effects than liraglutide. As guidelines continue to advocate for patient-centered treatment strategies, once-weekly albiglutide will be an important addition to the growing armamentarium of treatment options for adults with type 2 diabetes needing target glycemic control.

Probable Interaction Between Warfarin and Divalproex Sodium

Objective: A potential interaction between warfarin and divalproex sodium is described. Case Summary: A 65-year-old Arabic-speaking Egyptian woman chronically anticoagulated with warfarin for atrial fibrillation and a history of stroke presented to the anticoagulation clinic with an elevated international normalized ratio (INR) of 3.2. This was an increase of 1.4 over her previous INR of 1.8 only 9 days prior. Discussion with the patient’s daughter revealed the addition of divalproex sodium (a derivative of valproic acid) 250 mg twice daily to the patient’s medication regimen 6 days prior. Other contributing factors that could cause an elevated INR were ruled out. The patient’s total weekly dose (TWD) of warfarin was decreased from 22.5 mg to 20 mg, and the patient was instructed to return for a repeat INR in 1 week. On the day the patient was due to return for a repeat INR, she was admitted to the hospital and her INR was 2.2 on admission. Based on medication reconciliation information, the patient had decreased her warfarin TWD as instructed and had self-discontinued the divalproex sodium due to intolerable fatigue. During this time, the patient received no additional divalproex sodium. She was instructed to resume her previous TWD of warfarin of 22.5 mg on discharge and subsequently had a therapeutic INR (2.6) 11 days later. Discussion: Warfarin and divalproex sodium are commonly prescribed agents with few case reports to describe their interaction. Primary literature supports a multifactorial mechanism, including CYP450 metabolism inhibition and protein-binding displacement, both of which can result in an elevated INR. Use of the Drug Interaction Probability Scale indicated a probable interaction between warfarin and divalproex sodium. Conclusions: Patients receiving concurrent warfarin and divalproex sodium therapy should be monitored closely for changes in INR values as the combination may increase the INR and put the patient at increased risk for bleeding.

Prevalence of and factors that influence board certification among pharmacy practice faculty at United States colleges and schools of pharmacy

Board certification is a means of demonstrating expertise above the minimum licensing standards. For many health care professionals, this credential is a necessity. As pharmacists become involved in more advanced patient care services, board certification becomes an essential component to ensuring quality care. The prevalence of United States pharmacy practice faculty members who are board certified, however, is unknown. In addition, to our knowledge, factors that serve to motivate or discourage faculty from obtaining board certification have not been previously described; thus, 900 pharmacy practice faculty members listed in the American Association of Colleges of Pharmacy (AACP) online directory were invited to complete an online survey regarding motivators and barriers for board certification. In addition, a list of board-certified pharmacists, obtained from the Board of Pharmacy Specialties, was used to check the board certification status of all pharmacy practice faculty members listed in the AACP directory. In 2011, the prevalence of board certification among the 2867 pharmacy practice faculty members was 37% (1063 pharmacists), with the highest prevalence found among assistant professors (39.4%). A total of 322 faculty members (36% response rate) completed the survey; of these, 308 self-identified as pharmacy practice faculty, and their responses were included in the analysis. Current board certification in pharmacy specialties was reported by 163 respondents (52.9%); 14 (4.5%) were previously certified. Among the 308 respondents, the most common perceived reason why pharmacy practice faculty become board certified was the desire to be recognized as an expert in the field (71.5%). Those who were currently board certified indicated personal growth as the most important reason (60.1%). Those previously certified indicated no perceived benefit as the most common reason for not recertifying (71.4%). Among those never certified, no perceived need (52.0%) or benefit (44.8%) were the most common reasons for not becoming certified; however, a majority of those never certified (68%) stated that they would become board certified if there was no associated cost and they were confident they would pass. To increase the prevalence of board certification in pharmacy practice faculty at U.S. schools and colleges of pharmacy, the benefits of this credential must be addressed at each institution. Steps should be taken to assist and encourage board certification.

Utility of the SLUMS as a cognitive screening tool among a nonveteran sample of older adults

OBJECTIVES

To investigate the concurrent validity of the Saint Louis University Mental Status examination (SLUMS) by comparing the ability of the Mini-Mental State Examination (MMSE) and the SLUMS to predict performance on standard neuropsychological measures of memory and executive functioning.

DESIGN

Cross-sectional.

SETTING

University-based research clinic.

PARTICIPANTS

Community-dwelling adults (N = 170) age 60 years and older (Mage = 73.08; SD = 8.18).

MEASUREMENTS

The Trail Making Test (TMT), Rey Auditory Verbal Learning Test, Wisconsin Card Sorting Test (WCST), MMSE, and SLUMS.

RESULTS

The distributional properties of the SLUMS and the MMSE were directly compared. The SLUMS showed statistically a smaller mean, lower rank scores, and less skewness than the MMSE. Comparisons of the correlations of the screening tests with the neuropsychological measures indicated that the SLUMS demonstrated stronger relationships with the TMT compared with the MMSE. Multiple regression analyses were conducted to determine the ability of the SLUMS and the MMSE to predict scores on common neuropsychological tests after controlling for demographic variables. Results demonstrated that the SLUMS significantly predicted performance across all measures over the MMSE and demographic variables, with the exception of the WCST's perseverative errors. However, the MMSE does not add to the prediction of neuropsychological functioning over the SLUMS.

CONCLUSION

Although the SLUMS and the MMSE are strongly correlated, the SLUMS significantly adds to the prediction of neuropsychological measures beyond the MMSE scores. Our findings suggest that the SLUMS may be an appropriate measure to use as a screening tool among older adults and may have fewer ceiling effects than the MMSE.