Pharmacy News

Entries for July 2018

Injectable GLP-1 Agonists & Combination Products: Review for Inpatient Use

By Matthew Hecker, Pharm.D., PGY1 pharmacy practice resident, Sparrow Hospital, Lansing

 

Glucagon-like-peptide-1 (GLP-1) receptor agonists are a class of injectable and oral medications used in the treatment of type II diabetes. Injectable agents that are currently approved for use in the United States are: albiglutide (Tanzeum®), dulaglutide (Trulicity®), exenatide extended release (Bydureon®), exenatide immediate release (Byetta®), lixisenatide (Adlyxin®), and liraglutide (Victoza®). Combination products containing long acting (basal) insulin include: insulin degludec/ liraglutide (Xultophy®, and insulin glargine/lixisenatide (Soliqua®). GLP-1 agents are associated with increased glucose-dependent insulin secretion, decreased inappropriate glucagon secretion, increased B-cell growth and replication, slower gastric emptying and decreased food intake.


GLP-1 agonists have been shown to lower the hemoglobin (Hb) A1C in type II diabetes by one to 1.5 percent, which is only surpassed by the lowering effects of insulin therapy. In addition to its glucose lowering effects, the results from the LEADER trial (Liraglutide Effect and Action in Diabetes: Evaluation of Cardiovascular Outcome Results) have demonstrated that liraglutide (Victoza®) can provide additional cardiovascular benefits in patients with type II diabetes.4  The overall benefits of these agents in patients with type II diabetes is seen in their outpatient utilization.


While concerns exisit for therapy in all patients, inpatient concerns for GLP-1 agonists include their use in patients with renal impairment, hypersensitivity reactions to any GLP-1 products, a history of medullary thyroid carcinoma or multiple endocrine neoplasia syndrome type 2, and pancreatitis. The most commonly reported adverse drug effects are hypoglycemia, diarrhea, nausea and injection site reactions.1

 

Table 1: Characteristics of Injectable GLP-1 Agonists/Combination Products 1,2

Agent

 

Effect on HbA1C

Weight Loss

Hypoglycemia

Diarrhea

Nausea

Injection Site Reactions

Albiglutide

~1%

~1 kg

3-17%

13%

11%

18%

Dulaglutide

~1.5%

~2.5 kg

3-6%

9-13%

12-21%

0.5%

Exenatide ER

~1.5%

~2.5 kg

4-11%

1-20%

11%

17%

Exenatide IR

~1%

~2 kg

4-11%

11%

11%

13-17%

Liraglutide

~1.5%

~2.5 kg

16%

10-12%

20%

18%

Lixisenatide

~1%

~2 kg

n/a

8%

25%

18%

Degludec/ Liraglutide

~1% more than insulin degludec

~2.5 kg

 

Refer to Individual Agents

 

Insulin Glargine/ Lixisenatide

~0.5% more than insulin alone

~1.4 kg

 

Refer to Individual Agents

 

 

According to the American Diabetes Association (ADA), a review of anti-hyperglycemic medications concluded that GLP-1 receptor agonists show promise in the inpatient setting; however, proof of safety and efficacy await the results of randomized controlled trials. 3 There are potential administration concerns that could arise as a result of nursing staff’s unfamiliarity with these agents and their ability to cause hypoglycemia. Furthermore, cost of the medication may also be prohibitive in the inpatient setting.  Medication-related concerns such as renal impairment and gastrointestinal symptoms pose unique challenges in the acutely ill patient.


Although studies have shown that patients are able to improve glycemic control while taking these agents, there is relatively low benefit to using these agents in the acute inpatient setting.3 Patients can be sufficiently controlled with the use of basal and bolus insulin. Because of the potential risks associated with the GLP-1 agonists, the Pharmacy & Therapeutics Committee at Sparrow Hospital has classified these agents as non-formulary (Do Not Stock/Do Not Dispense). An automatic hold on GLP-1 agonists for the duration of hospitalization will occur, and providers will be prompted to utilize the basal and bolus insulin order set. Patients on combination products will be converted to basal insulin products based upon the recommended conversions provided in Table 2.

 

Table 2: Converting Combination Products to Long Acting Insulin Regimens at Sparrow 1

Combination Product

Conversion to Insulin Only Regimen

Degludec/ Liraglutide (Xultophy®)

Convert current insulin degludec dose to equivalent insulin detemir dose (Levemir®) 1:1 conversion of degludec to detemir

Insulin Glargine/ Lixisenatide (Soliqua®)

Convert current insulin glargine dose to equivalent insulin detemir dose (Levemir®) 1:1 conversion of degludec to detemir

 

 

References:

  1. Lexi-Drugs. Lexicomp Online. Hudson, OH: Wolters Kluwer Clinical Drug Information Inc. http://online.lexi.com. Accessed December 20, 2017.
  2. Therapeutic Research Center. Comparison of GLP-1. http://pharmacistsletter.therapeuticresearch.com/pl/ArticlePDF.aspx?&DocumentFileID=0&DetailID=340201&SegmentID=0. January 2017.
  3. American Diabetes Association (ADA). 14. Diabetes care in the hospital. Diabetes Care. 2017c;40(suppl 1):S120–S127.
  4. Marso SP, Daniels GH, Brown-Frandsen K et al. Liraglutide and cardiovascular outcomes in type 2 diabetes. N Engl J Med. 2016;375(4):311-22.
Posted in: Patient Safety
From Taught to Teach: Embracing the Transition from Student to Preceptor in a Residency Program

By Malak Abbas, Pharm.D., PGY1 pharmacy resident, Detroit Medical Center, Harper University Hospital, Detroit

The American College of Clinical Pharmacy (ACCP) in 2008 anticipated a shortage of qualified pharmacy preceptors, and as such, encouraged active integration of pharmacy residents into experiential teaching models to develop precepting skills early in their careers.1,2 Residency programs across the nation have since used this opportunity for professional development and began extending offers to residents to undergo formal training in clinical preceptorship. As I come to near completion of my residency journey, I cannot help but reminisce on the transition from learner to teacher and the challenges I have overcome during this journey. The transition from a pharmacy student to a pharmacy resident can be described as a rite of passsage with three major phases: separation, liminality and reaggregation.3,4

At first, the concept of becoming a preceptor immediately post-graduation may seem intimidating to new residents, as residents still have a student mindset and have yet to experience practicing independently. Students depend on faculty and clinical preceptors for validation of clinical competence. The initial phase of becoming a preceptor, known as the separation phase, occurs when residents learn to distance themselves from thinking like a student. It is during this phase when residents become forward thinkers and begin to apply the critical thinking skills and decision-making skills previously developed. Taking proactive measures to gain confidence during the separation phase will help with transition to the liminality phase by building professional interactions with increased communication.

The liminality phase is the phase between distancing oneself from their former identity as a student and entering a new role of being a preceptor. Transitioning into the role of precepting is challenging as it encompasses more than just having sufficient knowledge to teach. As a preceptor, residents learn to model high standards of professional behavior, display confidence and demonstrate strong character. A barrier to becoming a successful preceptor is ineffective time management skills. Residents will find that proactively preparing for the dynamic nature of precepting and effectively planning ahead will help overcome this challenge. Getting to know the students early in a rotation helps with developing effective teaching techniques by accommodating to the student’s individual learning style and gaining active participation. The transition phase prepares residents for the final reaggregation phase as they sharpen their communication skills, gain new confidence and a new perspective for analyzing and processing information.5

During the reaggregation phase, residents embrace the role of a preceptor and incorporate precepting into daily practice. New residents gain motivation to improve knowledge to pass on to others. Furthermore, with more experience, residents will improve in their ability to receive and give feedback and develop personal self-evaluation skills. During this phase, the full benefits of precepting are recognized including personal satisfaction and professional growth, staying current with evidence-based medicine, and influencing the learning experience of a student and future pharmacist.6

Becoming a preceptor with a positive influence on the profession was made possible through the endless support of mentors, utilizing available resources, attending preceptor development workshops and observing experienced successful preceptors. As I continue to grow in my role as a preceptor, I hope to continue to find opportunities to polish my teaching skills and further develop as a preceptor in order to provide future students with a quality experiential education experience.

References

  1. Haase KK, Smythe MA, Orlando PL et al. Quality experiential education. Pharmacotherapy. 2008; 28(12):1547
  2. Haase KH, Smythe MA, Orlando PL et al. Ensuring quality experiential education. Pharmacotherapy. 2008; 28(12):1548-51
  3. VanGennep, A. The rites of passage. Chicago: University of Chicago Press. 1960
  4. Barker ER1, Pittman O. Becoming a super preceptor: a practical guide to preceptorship in today's clinical climate. J Am Acad Nurse Pract. 2010 Mar;22(3):144-9
  5. Hammond DA, Norris KR, Phillips MS. Embracing Challenges When Co-Precepting Pharmacy Students. Hospital Pharmacy. 2014;49(4):348-354
  6. Marrs, Joel C., and Dan M. Rackham. "Residents' challenging role: preceptee, preceptor, or both?" Am J Health Syst Pharm. 2010; 67(3)239-43
Posted in: Professional Practice
Northern Michigan Society of Health-System Pharmacists Regional Society Update

By Matt Satkowiak, Pharm.D., BCPS, clinical pharmacist, Munson Medical Center, Traverse City and northern region representative

 

After a long and arduous winter in northern Michigan, we welcomed the thaw that brought a very busy and education-packed spring! We held our second Northern Michigan Society of Health-System Pharmacists (NMSHP) Annual Meeting, which took place in April at the Otsego Club and Resort in Gaylord. We offered four live continuing education (CE) credits on the topics of: Making Sense of Antiplatelet Therapy presented by Curtis Smith, Pharm.D., BCPS; Non-Opioid Options in Pain Management presented by Brad Beaman, Pharm.D., BCPS; Oncologic Emergencies presented by Mark Wagner, Pharm.D., BCOP and Munson Medical Center Residency Project Updates jointly presented by Rachel McLeod, Pharm.D., PGY1 pharmacy resident and Celine Quevillon, Pharm.D., PGY1 pharmacy resident. Our April monthly meeting offered one live CE credit on the topic of Management of Acute Traumatic Brain Injury presented by Kevin Przbylski, Pharm.D. Lastly, Munson Medical Center’s PGY1 and PGY2 residents presented their research projects at the May meeting. Cassie Diamond, Pharm.D. discussed the role pharmacists can play in the hospital discharge process; Molly Bosom, Pharm.D., provided insight on the use of argatroban in patients with suspected heparin-induced thrombocytopenia; Katelin Anderson, Pharm.D., explored the utility of penicillin skin testing in pregnant patients and Tate Feeney, Pharm.D., described pharmacist interventions in patients initiating oral chemotherapy medication.

 

We have now moved into our summer break and will resume regular meetings again in September. We plan to continue hosting meetings in Alpena and Traverse City and are looking to expand the number of sites that offer live video conferencing of our CE events. In the interim, we hope to gather for some fun events this summer in Northern Michigan.

 

For more information on upcoming fall meetings, please contact NMSHP president Emily Warner at EWarner3@mhc.net.

Posted in: Member News
Demonstrating Our Value Through the Triple Aim

By Michelle Dehoorne, Pharm.D., patient care services manager, St. John Hospital and Medical Center, Detroit

Efficient, high quality, affordable care is the “triple aim” in healthcare that we are all challenged to meet. Numerous articles demonstrate how pharmacists contribute to the healthcare team to meet aspects of the triple aim. Through appropriate medication management, pharmacists:

  • Ensure stewardship of resources.
  • Reduce unnecessary clinical and operational variation.
  • Improve clinical outcomes.

For several decades, pharmacists have focused on reducing supply costs through appropriate medication therapy, formulary and supply chain management. Pharmacists provide integral input in development of treatment guidelines, order sets and criteria for medication therapy which is critical in reducing variation. In the last several years, our profession has improved documentation and gained recognition for improving patient outcomes and quality measures. Lastly, pharmacists can also improve the patient and provider experience. Pharmacy technicians support our pharmacists so that we can be successful in each of these roles.

As pharmacists and pharmacy technicians, we believe we are vital in each of these areas. However, not everyone on the healthcare team or leadership may readily come to the same conclusion. When medical staff and leadership develop their strategic plans to ascertain the triple aim, pharmacists are not typically hard coded into them. They overlook the valuable role pharmacists play in the success of the team and the care of our patients. Despite the documentation in the literature of how we provide benefit, we are often challenged to garner the financial support to expand or initiate new services that improve patient outcomes and quality care.

A critical step in changing this pattern may be connected to the three aims as well: improved documentation of our ability to comprehensively improve the triple aim, credentialing and privileging. The need for greater recognition and understanding on the value, skill set and knowledge that pharmacy professionals bring to the multi-disciplinary healthcare team is important to achieving the ongoing success of our profession. First, a greater pool of research that demonstrates our comprehensive role in each aspect of the triple aim is necessary. This task will be time consuming and often difficult to demonstrate when quality outcomes are linked to a team and not an individual practitioner. Second, credibility and demonstration of our competence through credentialing are also needed. And lastly, privileging, when combined with credentialing, can provide opportunities for expanding our roles and advancing recognition for our contributions to the triple aim and the patient/provider experience.

In Michigan, the role of formal credentialing and privileging for pharmacists and pharmacy technician is limited. Credentialing provides a method to gain credibility with other members of the healthcare team, providers and leadership as it can improve their understanding of the competence, skill set and knowledge that pharmacists hold. Currently, each of our organizations use many different processes, words and training to achieve staff competence. Credentialing demonstrates a standard that can be accomplished all in an effort to demonstrate the overall value of Michigan pharmacy professionals. 

Posted in: Member News
Clinical Integration and Clinically Integrated Networks

By Tiffany Jenkins, Pharm.D., BCACP, clinical pharmacist, Affinia Health Network, Muskegon

 

Clinical integration initially arose over 20 years ago and early integration efforts were focused on creating a model to give hospitals and health-systems greater control over admissions, costs and contracting with payers. There are a number of definitions attributed to clinical integration, but the Department of Justice (DOJ) and Federal Trade Commission (FTC), as the regulatory bodies, defined clinical integration in 1996 as follows: "[clinical] integration can be evidenced by [a physician] network implementing an active and ongoing program to evaluate and modify practice patterns by the network's physician participants and create a high degree of interdependence and cooperation among the physicians to control costs and ensure quality."1 The DOJ and FTC became involved to ensure organizations were not creating these networks to just simply bargain for better rates and contracts, but to also improve quality of care for a population.

 

Early clinical integration efforts were focused on creating physician-hospital organizations (PHOs) or integrated delivery networks (IDNs). While these organizations still exist, some have evolved into clinically integrated networks (CINs). The CIN model is focused on the quadruple aim: reducing care costs, improving the health of the population, enhancing the patient experience and lessening physician burden.2 The business model of a CIN provides the infrastructure support for the network and ensures the following core competencies and capabilities are in place:3

  • Leadership and Governance: physicians from the network play a key role in the leadership of the CIN.
  • Integrated physicians: physicians and providers are engaged in the work, developing protocols and workflows.
  • Integrated care coordination network: consistent, evidence-based care is provided to patients and they are managed across the care continuum.
  • Data driven with analytics support: using data to measure network performance and to drive improvements.
  • Comprehensive networks: necessary services are available within the network (acute care, primary care, specialist care, etc.).
  • Payer alignment: work to ensure the best contracting possible and provide oversight on the performance of these contracts.

When reviewing the definition of clinical integration and better understanding the competencies required of a CIN, there are a number of areas where pharmacy intervention can play a role. Pharmacists are uniquely positioned to influence prescribing patterns, suggest lower cost alternatives and coordinate services with physician offices such as disease management or vaccinations. These types of interventions serve the patient as an individual, but also begin to move toward population health management which is essential to the success of a CIN. Many CINs are recognizing the advantage of having pharmacy input, especially as pharmacy costs continue to rise.

 

As always, if interested in learning more about ambulatory pharmacy, how to get a practice started, and finding practice resources, be sure to check out the MSHP Ambulatory Care toolkit at www.MichiganPharmacists.org/ambulatorycare/practicetoolkit.  

 

References

1. U.S. Department of Justice and Federal Trade Commission. Statements of Antitrust Enforcement Policy in Health Care. FTC website. https://www.ftc.gov/sites/default/files/attachments/competition-policy-guidance/statements_of_antitrust_enforcement_policy_in_health_care_august_1996.pdf. August 1996.

2. Bodenheimer T, Sinsky C. “From Triple to Quadrule Aim: Care of the Patient Requires Care of the Provider.” Ann Fam Med. 2014;12(6):573-76.

3.  PYA Healthcare Consultant and Audit & Accounting. Clinically Integrated Network: Who, What, When, Where, Why, and How?” PYA website. http://info.pyapc.com/hubfs/White-Papers/Clinically-Integrated-Networks-White-Paper-PYA.pdf. April 2013.

Posted in: Professional Practice