In this episode, we discuss the approach to deprescribing for several drugs such as benzodiazepine receptor agonists, cholinesterase inhibitors, memantine, antipsychotics, and antihyperglycemics.

Key Concepts

1. Medication appropriateness including indication and risk vs. benefit should be evaluated for all stages of life; however, more importantly in older individuals to address polypharmacy.
2. There is an emerging trend of deprescribing networks that conduct research and provide evidence-based recommendations for how to deprescribe certain medications used for specific indications.
3. Evidence-based deprescribing guidelines for PPIs, benzodiazepines, benzodiazepine receptor agonists, opioids, antipsychotics, cholinesterase inhibitors, memantine, and antihyperglycemics are available for patient-provider shared decision making. 
4. A general deprescribing approach is gradual tapering of the drug leading to discontinuation over several weeks while monitoring patients for withdrawal symptoms or benefits of discontinuation. 

References

• http://deprescribing.org
• https://www.australiandeprescribingnetwork.com.au

In this episode, we review the pharmacology, pharmacokinetics, adverse effects, monitoring, medicinal chemistry, and more of loop diuretics.

Key Concepts

1. Loop diuretics (furosemide, torsemide, bumetanide, ethacrynic acid) are the most potent type of diuretic and are used to relieve edema.
2. Loop diuretics cause an increased loss of sodium, chloride, potassium, hydrogen, magnesium, and calcium ions into the urine. Excessive loss of these ions manifests as hypokalemia, hypomagnesemia, and metabolic alkalosis.
3. Loop diuretics have an S-shaped dose response curve – a minimum dose is required for diuresis and a “ceiling” effect occurs at higher doses (leading to more ADRs). Doses should be individualized based on the clinical response of the patient.
4. Ethacrynic acid is incorrectly used in patients with a “sulfa” allergy. The other loop diuretics contain a sulfa moiety but are safe for use in patients with “sulfa” allergy (e.g. allergy to sulfamethoxazole-trimethoprim).
5. The TRANSFORM-HF trial strongly suggests that there is no clinical difference between furosemide and torsemide.

References

• Rachoin JS, Cerceo EA. Four nephrology myths debunked. J Hosp Med. 2011;6(5):E1-E5. doi:10.1002/jhm.703
• Strom BL, Schinnar R, Apter AJ, et al. Absence of cross-reactivity between sulfonamide antibiotics and sulfonamide nonantibiotics. N Engl J Med. 2003;349(17):1628-1635. doi:10.1056/NEJMoa022963
• Buggey J, Mentz RJ, Pitt B, et al. A reappraisal of loop diuretic choice in heart failure patients. Am Heart J. 2015;169(3):323-333. doi:10.1016/j.ahj.2014.12.009
• Mentz RJ, Anstrom KJ, Eisenstein EL, et al. Effect of Torsemide vs Furosemide After Discharge on All-Cause Mortality in Patients Hospitalized With Heart Failure: The TRANSFORM-HF Randomized Clinical Trial. JAMA. 2023;329(3):214-223. doi:10.1001/jama.2022.23924

In this episode, we interview Scott Glosner, PharmD, MPH, BCPS about his extensive experience working at Pfizer in medical outcomes and as a field medical director. Dr. Glosner will share his career journey from a clinical pharmacist transitioning into the pharmaceutical industry in the late 1990s and what current pharmacists and students should know about a job in a pharmaceutical company.

Key Concepts

1. Pharmacists are playing an increasingly important role within the pharmaceutical industry. Prior clinical experience is a significant advantage to applicants for these positions.
2. Key characteristics of a competitive pharmacist applicant for an industry position include strong communication skills, being perseverant (“tough skin”), being extremely persistent, and having real-world clinical experience.
3. Different companies and job positions within industry often require differing amounts of prior experience. Applicants with more than several years of experience (or equivalent fellowship experience) may be more competitive for positions. Standing out in any way, whether board certification, doing research, networking, etc. is important for any applicant.
4. In the future, pharmacists in industry may be playing a greater role in the oncology space, social determinants of health, emerging topics (such as gene therapy), and being capable of analyzing and interpreting “real world” clinical trial data.

Questions for Dr. Scott Glosner? He can be reached at scott.glosner@pfizer.com or on LinkedIn (https://www.linkedin.com/in/scott-glosner-b743234).

In this episode, we will discuss the advantages and disadvantages of a rate versus rhythm control strategy for atrial fibrillation.

In this episode, we discuss the importance of accurately recognizing depressive symptoms in patients with kidney disease and provide review the limited available literature regarding treatment in this population. We then discuss guidelines to determine some of the best treatment options for this unique subgroup of patients.

In this episode, we take a closer look at deuteration, specifically involving the medication deutetrabenazine (discussed back in episode 76). We feature a guest contributor from our pharmacy sciences department who assists us as we look at the drug design aspects of this unique molecule and its implications for research moving forward.

In this episode, we discuss some ways APPE students not only survive, but excel in the APPE rotations.

In this episode, we will review the diagnosis and treatment of heparin-induced thrombocytopenia (HIT).

In this episode, we interview Kathleen Lynch, PharmD and Ciantel (Adair) Blyler, PharmD, coauthors of the New England Journal of Medicine article, published in March 2018, investigating the role of pharmacist-led interventions for blood pressure reduction in black barbershops.

In this episode, we interview Janeen Winnike, Dean of the Office of Students Affairs at the RFUMS College of Pharmacy, regarding transitions from a student life to a practitioner life. With her previous role as an HR official within a large community pharmacy chain, she offers some “do’s and don’ts” for students transitioning into new practitioners.

In this episode, we discuss five clinical pearls about pulmonary embolism ranging from PE diagnosis, classification, and treatment. We specifically examine when and how alteplase is given for PE and its use with concurrent anticoagulation.

In this episode, we discuss two new agents (valbenazine and deutetrabenazine) -- the first of their kind to receive FDA approval to manage tardive dyskinesia most commonly associated with antipsychotic use.

In the previous episodes, we discussed how we should evaluate a patient’s bleeding and clotting risks as well as looked at recommendation for management for various anticoagulants. In this episode, we will continue the discussion to management of antiplatelets as well as when to resume both antiplatelets and anticoagulants following a procedure.

In this episode, we will discuss the definition of REMS (Risk Evaluation and Mitigation Strategies), why they exist, the role of FDA in administering REMS, types and examples of REMS, and how they impact pharmacy practice.

Key Concepts

1. The REMS (Risk Evaluation and Mitigation Strategies) program was developed in 2007 as part of the FDA’s drug risk management strategies designed to balance risk and benefits of certain drugs.
2. Elements of REMS vary depending on the drug, but commonly include medication guides, communication plans, and other elements to assure safe use.
3. REMS can require patients, providers, and pharmacies to take certain actions including training, registration, enrollment, safety monitoring, documentation of safety concerns, and follow prescribing and dispensing regulations. 
4. The FDA captures and assesses data on a regular basis to make changes in the REMS program. It also has authority to enforce compliance and take punitive actions against non-compliant parties.

References

• Risk Evaluation and Mitigation Strategies. Food and Drug Administration. May 16, 2023. Accessed October 17, 2023. https://www.fda.gov/drugs/drug-safety-and-availability/risk-evaluation-and-mitigation-strategies-rems

In this episode, we will discuss some important factors to consider in management of various anticoagulants. We will also provide agent specific pharmacodynamic and pharmacokinetic based recommendations.

In this episode, we discuss the efficacy and safety of probiotics for the prevention of antibiotic-associated diarrhea (AAD) and Clostridium difficile-associated diarrhea (CDAD).

In this episode, we will review the surprising results of the VA/DoD's 2017 Clinical Practice Guidelines on Management of PTSD, particularly as it relates to the use of one particular agent, prazosin.

In this episode, we review the important changes in 2017 ACC/AHA guidelines for hypertension management in adults.

In this episode, we discuss the difficulty in identifying adverse drug reactions (ADR) that ACTUALLY occur from a drug therapy, how tertiary drug references (such as Micromedex or LexiComp) may be misleading, and what tips and tricks you can use to recognize the most clinically relevant ADRs for patient counseling.

In this episode, we interview Dylan Moe, PharmD, our very own alumnus, regarding the new Illinois rule requiring patient counseling for all new prescriptions and inquire how the new rule has impacted his pharmacy, work environment, and his opinions on the implementation of the rule.

In this episode, we will discuss the current state of benzodiazepine use, expected trends in prescribing, and risks associated with use. Lastly, we will discuss techniques for ensuring that a benzodiazepine taper is performed in a safe manner with lowest risk of harm.

In this episode, we discuss new evidence for cardiovascular outcomes in diabetics based on the LEADER trial (liraglutide) and CANVAS trials (canagliflozin). We also discuss the new FDA warning for canagliflozin regarding amputation risk.

In this episode, we discuss updates in diabetes management that includes nuances from the ADA’s Standards of Care 2017. We also review some newer pharmacologic agents, a fixed dose GLP-1 agonist and basal insulin combinations.

In this episode, we discuss three "older" antihypertensives that are not preferred first-line therapies: clonidine, methyldopa, and minoxidil.  We outline why these agents are not first-line therapies and review their pharmacology and adverse effect profiles.

In this episode, we review the role and indications of thrombolytics in acute ischemic stroke. The efficacy, safety, administration considerations, and cost between alteplase and tenecteplase are compared and contrasted.

Key Concepts

1. Alteplase (Activase) is a recombinant DNA version of human TPA (tissue plasminogen activator). Tenecteplase (TNKase) is similar to human TPA except it has three amino acid changes that result in a longer half-life and higher fibrin specificity.
2. In patients with stroke, alteplase is given as a bolus followed by a 60-minute infusion. Tenecteplase is given as an IV bolus without the need for an infusion due to its longer half-life.
3. Tenecteplase is at least as safe and effective as alteplase in acute ischemic stroke (with some studies showing greater benefit with tenecteplase).
4. In patients with acute ischemic stroke who are candidates for mechanical thrombectomy, thrombolytics (with alteplase or tenecteplase) will still be given in patients who meet inclusion criteria and have no exclusion criteria.

References

• Powers WJ, Rabinstein AA, Ackerson T, et al. Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association [published correction appears in Stroke. 2019 Dec;50(12):e440-e441]. Stroke. 2019;50(12):e344-e418. doi:10.1161/STR.0000000000000211
• Campbell BCV, Mitchell PJ, Churilov L, et al. Tenecteplase versus Alteplase before Thrombectomy for Ischemic Stroke. N Engl J Med. 2018;378(17):1573-1582. doi:10.1056/NEJMoa1716405
• Kobeissi H, Ghozy S, Turfe B, et al. Tenecteplase vs. alteplase for treatment of acute ischemic stroke: A systematic review and meta-analysis of randomized trials. Front Neurol. 2023;14:1102463. Published 2023 Jan 23. doi:10.3389/fneur.2023.1102463

In this episode, we discuss the history of ergot products for treatment of migraines. We compare their safety and efficacy to newer agents such as the triptans and assess their resultant place in therapy.

In this episode, we discuss several aspects of serotonin syndrome including the typical clinical presentation, its etiology and common drug-induced combinations, and how to appropriately manage the syndrome.

In this episode, we discuss the pathophysiology of embolic stroke in patients with atrial fibrillation and review the use of left atrial occlusion devices, such as the WATCHMAN device, to reduce the risk of stroke in patients with atrial fibrillation without the use of anticoagulants like warfarin.

In this episode, we review the 12 recommendations from the 2016 CDC Guideline for Prescribing Opioids for Chronic Pain.  These recommendations are intended to help curb the opioid epidemic and provide guidance to healthcare providers regarding safer use o

In this episode, we discuss the concept of professional advocacy, with a particular focus on how to advocate for the profession of pharmacy and what tools and organizations are available to assist in being an advocate.

In this episode, we discuss with Dr. Megan Hartranft the five oncology drugs that every pharmacist should know about, which is a great review for P4 students who are currently preparing for the NAPLEX.  We cover cyclophosphamide, cisplatin, methotrexate, doxorubicin, and vincristine.

In this episode, we discuss the newest definition of sepsis and septic shock according to the Sepsis-3 criteria and the 2016 Surviving Sepsis guidelines.  We also review the scoring systems of “qSOFA” and “SOFA” and use a patient case to help demonstrate the new definitions.

In this episode, we discuss the overuse of proton pump inhibitor (PPI) therapy and several concerns regarding chronic use of this medication class, including hypomagnesemia, fracture risk, low seurm B12 levels, anemias, and increased risk of certain infections.

In this episode, we discuss the new FDA categorizations of biosimilars, the legal implications of biologic/biosimilar prescriptions, and the new "follow-on" approval pathway of Basaglar, a new insulin glargine U-100 product.

In this episode, we discuss the SPRINT trial (intensive vs. standard blood pressure control) using a case vignette of Mr. Wilson, a 55 year old patient presenting to a clinic with a blood pressure of 139/89 mmHg.

In this episode, we briefly review RSV (respiratory syncytial virus) infections and focus on new data supporting the use of two different RSV vaccines (Abrysvo and Arvexy) in preventing RSV infections in older adults and in pregnant women.

Key Concepts

1. RSV is a contagious respiratory virus that is usually mild and self-limiting in most patients but can cause severe disease especially in young children or older adults with certain risk factors.
2. The FDA recently approved two vaccines for RSV (Abrysvo from Pfizer and Arexvy from GSK). The initial FDA approval was for adults 60 years of age and older; however, the FDA recently granted an additional indication for Abrysvo for pregnant women (to prevent the infant from severe RSV infection once born).
3. When studied in older adults, both vaccines did meet efficacy criteria but the incidence of RSV infection was relatively low and thus the number needed to treat (NNT) is high. Both studies were done at times with lower RSV prevalence - the NNT would likely be more favorable during RSV outbreaks.
4. Unlike Abrysvo, Arvexy (GSK) contains an adjuvant to improve the immune response. Although direct comparisons of efficacy and safety are not appropriate, Arvexy does appear to elicit more systemic adverse effects such as fever, myalgias, headache, and fatigue.

References

• Respiratory Syncytial Virus Infection (RSV). Centers for Disease Control and Prevention. https://www.cdc.gov/rsv/index.html
• Abrysvo (respiratory syncytial virus vaccine). US Food & Drug Administration. https://www.fda.gov/vaccines-blood-biologics/abrysvo
• Arexvy (respiratory syncytial virus vaccine, adjuvanted). US Food & Drug Administration. https://www.fda.gov/vaccines-blood-biologics/arexvy
• Use of Respiratory Syncytial Virus Vaccines in Older Adults: Recommendations of the Advisory Committee on Immunization Practices — United States, 2023. Morbidity and Mortality Weekly Report (MMWR). July 21, 2023 / 72(29);793-801. https://www.cdc.gov/mmwr/volumes/72/wr/mm7229a4.htm
• CDC. ACIP Recommendations. Last reviewed August 4, 2023. www.cdc.gov/vaccines/acip/recommendations.html. Accessed August 23, 2023.
• RENOIR - Walsh EE, Pérez Marc G, Zareba AM, et al. Efficacy and Safety of a Bivalent RSV Prefusion F Vaccine in Older Adults. N Engl J Med. 2023;388(16):1465-1477. doi:10.1056/NEJMoa2213836
• AReSVi-006 - Papi A, Ison MG, Langley JM, et al. Respiratory Syncytial Virus Prefusion F Protein Vaccine in Older Adults. N Engl J Med. 2023;388(7):595-608. doi:10.1056/NEJMoa2209604
• MATISSE - Kampmann B, Madhi SA, Munjal I, et al. Bivalent Prefusion F Vaccine in Pregnancy to Prevent RSV Illness in Infants. N Engl J Med. 2023;388(16):1451-1464. doi:10.1056/NEJMoa2216480
• RSV-NET Interactive Dashboard. Centers for Disease Control and Prevention. https://www.cdc.gov/rsv/research/rsv-net/dashboard.html
• ACIP Meeting Information - Meeting Materials. https://www.cdc.gov/vaccines/acip/meetings/index.html

In this episode, we discuss precepting tips and clinical pearls with Dr. Brad Cannon.

In this episode, we discuss more of the most important drug interactions, including grapefruit juice with statins and calcium channel blockers, QT prolonging medications, levothyroxine with cations and PPIs, and PDE-5 inhibitors with nitrates.

In this episode, we discuss some of the most important drug interactions, including serotonin syndrome, St. John's wort, statins and CYP inhibitors, and antihypertensive medications with NSAIDs.

In this episode, we discuss two new naloxone devices (intramuscular Evzio and intranasal Narcan) and review new state laws that are expanding the role of pharmacists in dispensing these opioid reversal products.

In this episode, we discuss three shocking recommendations from the CHEST 2016 VTE guideline update.  We focus on (1) the debate between NOAC, DOAC, or TSOAC nomenclature, (2) the controversial recommendation of preferring NOACs over warfarin in VTE treatment, and (3) the efficacy of compression stocking for prevention and treatment of post-thrombotic syndrome.

In this episode, we discuss RFUMS's Interprofessional Community Clinic (ICC), a student-run clinic providing health services to underserved populations.  The students in this episode discuss how the ICC evolved and highlight pearls and challenges in starting and running a free health clinic or screening event.

In this episode, we discuss the self-care of nasal congestion and allergies, including systemic/topical decongestants, nasal corticosteroids, antihistamines, cromolyn, and alternative medicine therapies.

In this episode, we discuss self-care of cough and cold, including using PQRSTA or SCHOLAR-MAC to prompt relevant questions for patients, codeine, dextromethorphan, diphenhydramine, camphor, menthol, and guaifenesin.

In this episode, we discuss self-care of constipation including bulk-forming laxatives, hyperosmotic laxatives, emollient laxatives, lubricant laxatives, saline laxatives, and stimulant laxatives.

In this episode, we discuss self-care of heartburn and dyspepsia, including antacids, bismuth subsalicylate, H2 blockers, and PPIs.

In this episode, together with our faculty colleague, Dr. Roberta Dume, PharmD, BCPP, we discuss the pharmacologic options and evidence for the treatment of opioid use disorder (OUD) and how pharmacists play a vital role in assisting patients suffering from opioid use disorder.

Key Concepts

1. The treatment for OUD should be provided by either the treating clinician or a certified Opioid Treatment Provider (OTP) using one of three FDA-approved therapies which include buprenorphine, methadone, and naltrexone.
2. Selection of the OUD treatment depends on availability of treatment provider; pharmacologic agent specific factors such as efficacy, dose titration, safety, and need for detoxification; and patient factors such as ability to safe-keep medications, adherence to  required clinic visits, or presence of comorbidities. 
3. Pharmacists can play an important role for patients needing OUD by providing treatment education, treatment induction, monitoring treatment outcomes, harm reduction by providing naloxone and related education, and utilizing preventative strategies such as monitoring opioid use, offering non-opioid pain management options, and promoting safe storage and disposal of opioids. 

References

• SAMHSA. Tip 63. https://store.samhsa.gov/sites/default/files/pep21-02-01-002.pdf
• SAMHSA. Medications for substance use disorders. https://www.samhsa.gov/medications-substance-use-disorders
• NIDA. Medications to treat opioid use disorder research report. How effective are medications to treat opioid use disorder? https://nida.nih.gov/publications/research-reports/medications-to-treat-opioid-addiction/efficacy-medications-opioid-use-disorder

In this episode, we discuss the science of carbohydrate-based sugars, sugar alcohols, artificial sweeteners, and natural sweeteners with Dr. Eric Walters, author of the book "The Sweetener Book" and Professor at Rosalind Franklin University.

In this episode, we review the clinical presentation and treatment of diabetic ketoacidosis (DKA).

In this episode, we discuss the BRIDGE trial, which investigated whether patients with atrial fibrillation on warfarin need a parenteral anticoagulant "bridge" in preparation and after an elective surgical procedure.