American Journal of Health-System Pharmacy最新文献

Purpose: This article concisely evaluates current targeted therapies that have received regulatory approval for chronic lymphocytic leukemia (CLL). Mechanisms of molecular pathogenesis and their therapeutic implications, current and novel targeted therapies, and supportive care are discussed.

Summary: CLL is a common lymphoproliferative neoplasm of mature but immunologically incompetent B cells in older adults. Over the past 2 decades, robust research has shown that CLL pathogenesis is a multistep process that includes, but is not limited to, (1) clonal selection, expansion, and transformation; (2) aberrant B cell signaling pathways; (3) sequence heterogeneity in the gene encoding the immunoglobulin heavy chain variable region (IGHV); (4) impaired apoptosis; and (5) interactions between CLL cells and their microenvironment. The development of oral targeted therapies against some of these molecular abnormalities has led to improved survival outcomes over traditional chemoimmunotherapy. Current oral targeted therapies that have received regulatory approval include continuous therapy with Bruton's tyrosine kinase inhibitors (BTKis) and fixed-duration therapy with the B cell leukemia/lymphoma-2 inhibitor (BCL-2i) venetoclax. These agents may be used either alone or in combination in the treatment-naive setting, as well as in relapsed or refractory disease. This review contributes to understanding of the molecular pathogenesis of CLL with therapeutic implications. It summarizes key advances in oral targeted therapies and emerging innovative targeted therapies (eg, novel BTKis, BTK degraders, and novel BCL-2is) and highlights supportive care in optimizing treatment-related adverse effects.

Conclusion: Treatment options for CLL continue to evolve. Current treatment selection is based on clinical and patient-specific considerations. Emerging novel therapies to overcome treatment resistance and strategies to optimize supportive care generate opportunities for pharmacists to advance practice and improve patient safety.

Purpose: There are hospitalized patients with chronic opioid use who will experience signs and symptoms of opioid withdrawal who were not on medications for opioid use disorder (OUD) prior to admission, do not want to start or are unable to start medications for OUD during admission, and want to limit or avoid the use of opioids. The purpose of this scoping review was to assess the potential effectiveness and safety of using non-opioid agents for managing acute opioid withdrawal in acute care settings.

Methods: PubMed (inception to 2024), Embase (inception to 2024), and Cochrane Library (inception to 2024) were the databases evaluated for the literature search. Bibliographies of full-text articles were reviewed for additional relevant papers.

Results: Twenty-eight studies evaluating nonopioid agents for managing acute opioid withdrawal were identified in the literature search. The agents could be divided into 4 broad mechanistic categories: α-adrenergic receptor agonists, N-methyl-d-aspartate (NMDA) antagonists, gamma-aminobutyric acid (GABA) modulators, and serotonergic agents. Of these drug classes, the available literature suggests the α-adrenergic receptor agonists clonidine and lofexidine have the best evidence of efficacy as alternative agents for acute opioid withdrawal, although the majority of studies comparing such agents to opioids for opioid withdrawal were conducted well before the rise in synthetic opioid overdose deaths and have other methodologic issues that limit firm conclusions concerning efficacy and, particularly, safety.

Conclusion: For the nonopioid alternative agents that have been studied for acute opioid withdrawal, there is more evidence supporting the efficacy of α-adrenergic receptor agonists as opposed to NMDA antagonists, GABA modulators, or sertonergic agents; however, more research is needed regarding the efficacy and safety of nonopioid alternatives for acute opioid withdrawal in order to better guide clinical decision-making.

Purpose: Well-educated and well-trained pharmacy technicians play an integral part in the operation of pharmacies. However, recently, the pharmacy technician workforce has been declining due to many factors, including low salary, limited career advancement, and increasing responsibilities. Here a pharmacy technician student education and training partnership among a state pharmacy association, a community college, and a healthcare system is described.

Summary: Through this novel partnership, the state association provides the curriculum and instructors for the community college to offer the course and the health system provides real-world experiences. The dedicated course with didactic and simulation opportunities, coupled with the experiential learning opportunity, following successful course completion, can prepare pharmacy technician students to enter the workforce and potentially address recent workforce shortages.

Conclusion: Collaboration among a state pharmacy association, a community college, and a healthcare system or pharmacy may be a viable model in providing pharmacy technician education and training programs. Partnered health systems or pharmacies may benefit from having a consistent pool of well-trained, diverse, and dedicated pharmacy technicians to add to the workforce.

Purpose: Binge eating disorder (BED) is a psychological disorder that poses several functional consequences for those affected. Management of BED centers around psychological and pharmacological treatment modalities, which have been associated with variable efficacy and the potential for severe adverse effects. Glucagon-like peptide-1 receptor agonists (GLP-1 RAs), approved by the Food and Drug Administration for conditions such as diabetes and weight management, are an emerging therapy of interest in BED.

Summary: In this case report, we describe use of dulaglutide for treatment of a patient with BED, obesity, and type 2 diabetes mellitus. The patient's baseline binge eating scale (BES) score, glycated hemoglobin level, body mass index (BMI), and weight were obtained. Following these baseline assessments, dulaglutide 0.75 mg once weekly was initiated to optimize management of the patient's type 2 diabetes. Follow-up measurements were obtained 6 weeks after initiation, at which time reductions in the patient's BES score, BMI, weight, and BED symptoms were observed. Moreover, dulaglutide was well tolerated without adverse drug events.

Conclusion: This case report describes the use of dulaglutide in the management of mild BED in the setting of comorbid type 2 diabetes and obesity. Further research is necessary to evaluate the long-term effectiveness of GLP-1 RAs in the management of BED and to determine the optimal duration and dose.

Purpose: Acute care pharmacy practice continues to evolve, and useful pharmacist productivity models should reflect contemporary practice. The purpose of this project was to rebuild an acute care pharmacist productivity model to accurately capture and categorize the variable workload of acute care generalists and specialists using electronic health record (EHR) data reports and analytic capabilities.

Summary: The acute care pharmacist productivity model was rebuilt with 5 variable workload drivers, including order verification, medication preparation verification (product check), clinical scoring, pharmacist-documented progress notes, and pharmacy intensity score-weighted patient admissions and patient days. Reports from the EHR database were used to capture all workload drivers. For each variable workload driver, more granular categories included in the reports were assigned time standards based on the work's complexity. Work output data, represented as units of service, were mapped by the user's job title (ie, generalist or specialist) and by the inpatient department.

Conclusion: The rebuilt pharmacist productivity model leverages EHR data and standard documentation of patient care activities to capture workload and reflect clinical practice. The EHR-generated reports enabled construction of a comprehensive and sustainable productivity model for acute care pharmacists without the need for additional manual documentation for productivity purposes.

Purpose: The purpose of this study was to characterize the current state of training in the care of critically ill obstetric patients for postgraduate year 2 (PGY2) critical care pharmacy residents across the US. Additionally, we sought to compare the level of comfort in caring for these patients between those who received training during their residency and those who did not.

Methods: This was a descriptive analysis of the training provided to PGY2 critical care pharmacy residents. Two surveys were sent to residency program directors (RPDs) and to current residents and recent graduates of PGY2 critical care pharmacy training programs.

Results: A total of 44 RPDs responded to the survey. Of the respondents, 9.1% indicated that their program has an obstetrics rotation while 65.9% of programs include case reviews or topic discussions. Forty-two current residents and recent graduates of PGY2 critical care pharmacy training programs responded to the survey. Of those who responded, 23.8% indicated that they had a formal rotation experience. The median comfort level in care of critically ill obstetric patients was significantly higher for pharmacists who had received training vs those who had not (P < 0.001).

Conclusion: These survey results highlight an opportunity for more thorough training in care of critically ill obstetric patients for PGY2 critical care pharmacy residents. This training is associated with increased comfort level in caring for these complex patients.

Purpose: The centralization of prior authorization services to prevent denials and improve reimbursement measures at 2 community hospital-based infusion clinics is described.

Summary: Current process gaps at 2 hospital-based infusion clinics within the health system were leading to a significant denial burden and high out-of-pocket expenses to patients. As a result, authorization and benefit verification processes were centralized by deploying financial coordinators (FCs) at the beginning of fiscal year 2023. A retrospective cohort data review of participating payer claims from adult patients treated at the infusion clinics compared the pre- and postcentralization financial impact. The primary endpoint was the change in the number and cost of denials related to FC workflow. Secondary endpoints included the change in the number and cost of all initial denials, denial type, and success of local denial recovery efforts. Denials related to FC workflow decreased by 68% in the postcentralization period, with a cost reduction of approximately $1.4 million. Total initial denials decreased by 50%, resulting in a cost savings of $3.8 million. Among the top 10 most common denials, 4 were deemed related to FC workflow and declined dramatically after centralization. Local denial recovery efforts resulted in an organizational savings of $0.2 million and a patient savings of $0.19 million.

Conclusion: Centralization of prior authorization services via utilization of FCs significantly reduced the number and cost of preventable denials and positively impacted denial recovery efforts.