Respecting the Patient’s Choice: A Case of Possible Drug-Induced Parkinsonism

This report describes a case of likely drug-induced Parkinsonism (DIP) identified by the pharmacist. A 54-year-old female patient was referred by a physician to the pharmacist in a rural, integrated care team for a comprehensive medication review (CMR) to address the patient’s concerns of possible Parkinson’s disease (PD). While PD may occur over the progression of age, medications that affect dopamine transport can also cause DIP, a secondary form of Parkinson’s disease. Although PD and DIP may be clinically indistinguishable, differentiation may be possible by reviewing a patient’s medication history for any potential causative drugs correlating to the timeline of the onset of symptoms. In this case, the pharmacist reviewed the medication profile and identified medications that could be responsible for causing DIP, specifically bupropion. The pharmacist suggested discontinuing bupropion and identifying another option for treating depression. The patient appreciated the suggestion and education, but ultimately preferred continuing her bupropion therapy instead of discontinuing therapy or changing to an alternative agent. At a follow-up meeting with the pharmacist, not only was the patient still experiencing tremors despite taking carbidopa/levodopa, but additional medications known to be potential inducers of tremors were added to her regimen. Although the pharmacist repeatedly discussed DIP with the patient and believed stopping bupropion would determine whether her Parkinsonism was PD or DIP, ultimately the patient continued taking bupropion because of concerns related to depression severity and the impact on her well-being. The patient’s wishes were respected.

Addison’s Disease Presenting as Acute Renal Failure and Hyperkalemic Paralysis: A Rare Presentation

Hyperkalemic paralysis in the setting of acute renal failure can lead to a missed or delayed diagnosis of adrenal insufficiency as the raised potassium can be attributed to the renal failure. Acute kidney injury as the presenting manifestation in an adrenal crisis due to Addison’s disease has been rarely reported in the literature. Here, we present the case of a young 37-year-old male who came with hyperkalemic paralysis and acute renal failure needing emergent hemodialysis. He had no past medical history and no medication history. His hyponatremia, hypotension, and hyperkalemia pointed to a picture of adrenal insufficiency confirmed by undetectable serum cortisol, elevated ACTH, renin, and low aldosterone levels and imaging. Replacement steroid therapy was given, and the patient made a steady recovery. He was advised on the importance of compliance to treatment at discharge to prevent another crisis event. Acute renal failure with hyperkalemia as a presenting manifestation of Addison’s disease can be very misleading. It is especially important to be vigilant of adrenal insufficiency in such patients as the hyperkalemia is resistant to standard therapy of insulin dextrose and can precipitate fatal arrhythmia if treatment is delayed.

A Multidisciplinary Approach to Screen Deployment-Limiting Health Conditions

ABSTRACT Introduction Disease non-battle injuries (DNBIs) are responsible for the majority of hospital admissions for soldiers in combat since the Vietnam War The U.S. Army prepares soldiers to deploy through a multistage process known as the Soldier Readiness Program (SRP). The current processes are reactive and address deployment-limiting health conditions (DLHCs) and the need for intervention and/or medical waivers late in the SRP process. This may compromise the quality and efficiency of pre-deployment medical clearance and result in DNBI medical evacuation from theater, which is costly and reduces the effectiveness of the unit. Implementation of a proactive and standardized screening process focused on behavioral health-related medical evacuations and psychotropic medication use will facilitate timely and effective interventions to improve readiness. Methodology The primary objective of this proof-of-concept (POC) study was to develop a standardized and sustainable process, known as the deployment-limiting medication (DLM) surveillance process, to screen soldiers for DLHCs that prevent mobilization. The A-3 performance improvement model was utilized to identify the root causes of limitations with the current medical SRP and to develop solutions. This process utilized the DLHC tool, a report created by the Defense Health Agency, as a basis to identify soldiers that require continued chart review based on prescription fill history. The results of the report were further assessed using published deployment eligibility standards and focused on psychotropic medications. Secondary measures [included] validation of the DLHC tool by assessing the accuracy of the DLHC report. This was determined by the proportion of soldiers screened who actually required intervention and/or waivers per deployment policy. This study took place within an Infantry Brigade Combat Team (IBCT). Results From August 2019 to March 2020, 959 soldiers in the IBCT were screened under the DLM surveillance process for DLHCs related to mental health and psychotropic medication use. The percentage of completed screenings of psychotropic-related DLHCs in the IBCT reached 100% after 3 months of implementing this POC study. After thorough chart review, a total of 421 soldiers met criteria for a medical intervention and/or waiver with 8% of these soldiers identified with a preexisting medical profile. The DLHC tool’s ability to use medication history to accurately predict the need for an intervention and/or medical waiver was 59% (654/1,112 medications). Soldiers identified using the DLM surveillance process that did not meet criteria predominately involved antidepressant, anticonvulsant, and central nervous system DLHC categories. If the psychotropic-related DLHC categories are optimized in future reports, the report’s accuracy may be increased to 90% while decreasing the time to complete the monthly review. Conclusion The DLM surveillance measures were successfully incorporated into the SRP process to proactively screen for DLHCs. Early identification of DLHCs allowed for proper identification of medical intervention and/or waiver needs and may decrease deployment complications. This process may help to improve a soldier’s deployability and improve overall readiness of the IBCT.

Perspectives From a Regional Plastic Surgery Centre on Evidence for the Purported Link Between SGLT2 Inhibitors and Fournier's Gangrene

Introduction: The recent report issued by the MHRA indicating an association of Sodium glucose linked transporter type 2 (SGLT2) Inhibitors with the contraction of Fournier's Gangrene (FG), has been drawn with insufficient supporting evidence and without an adequately powered study to make any meaningful assertions or recommendations. We aimed to look specifically at the currently available dataset used to link SGLT2 Inhibitors to FG and highlight what conclusions or inferences can meaningfully be made, in particular the power of any study that would be required to make sensible conclusions.Methods: World literature review of SGLT2 Inhibitors and FG was performed. With a subsequent 10-year review of cases of FG seen in a regional burns and plastics centre. Data was collected retrospectively from the coding department at Whiston Hospital for all patients with necrotising fasciitis. An electronic document management system was used to identify patients with FG specifically as well as their diabetes state and medication history.Results: Seventy-eight patients were admitted with FG, of whom 32 had diabetes mellitus (DM). Of those with DM none was taking an SGLT2 Inhibitor, 17 patients were taking metformin, a further nine patients were taking a second line medication and 14 required insulin injections.Discussions: DM is a known major risk factor for FG, which is clearly observed in our patient cohort. The risk of patients with DM developing FG is irrespective of the medication patients are taking. The current articles and reports published have little ground to claim an association between SGLT2 Inhibitors and FG and are missing the crucial message that needs to be conveyed to the public: that DM is a major risk factor for FG and patients suffering with diabetes need to be extra vigilant.

SPECTRUM OF DISEASE, MANAGEMENT, EFFICIENCY, CLINICAL PROFILE AND OUTCOMES OF RETROVIRAL DISEASE PATIENTS

HIV is a virus that targets and alters the immune system, increasing the risk and impact of other infections and diseases. Without treatment, the infection might progress to an advanced disease stage called AIDS. A prospective study was conducted for a period of 6 months in a tertiary care hospital with the sample size of 102 patients. A data collection form was taken, which includes the details of demographics date of visit to the hospital, diagnosis, past and current medication history. 102 Inpatients and Outpatients diagnosed with HIV were considered. For the management of HIV, 52 % of 2 NRTI and 1 NNRTI combination and 35 % of 2 NRTI and 1 integrase inhibitor combination were used. The drug usage pattern was found to be tenofovir 74.5 %, lamivudine 83.3 % and Efavirenz 50.9 %. The percentage of subjects with opportunistic infections was 66.6 % and, among these opportunistic infections, tuberculosis was found to be 47.05 %. The viral load after 6 months of ART was found to be undetectable in 95.09 % patients. The levels of CD4 counts were raised after initiation of the ART in 6 months of duration. The death rate was found to be 4.90 %. Due to highly active antiretroviral therapy and effi cient opportunistic infection management, the patients had elevated CD4 levels and undetectable viral load. Hence HAART is highly effi cient in management of HIV which ultimately improves the quality of life of patients.

Mean platelet component in nonproliferative and proliferative diabetic retinopathy

Introduction: Diabetic retinopathy (DR) remains a visually debilitating disease and is commonly classified according to its severity as non-proliferative DR (NPDR) or proliferative DR (PDR). Those suffering from PDR tend to have worse vascular complications and prognosis. Platelets exposed by vasculopathy caused by DR maybe activated to try to maintain haemostasis. This activity can be illustrated by the mean platelet component (MPC). Therefore, by MPC monitoring we may be able to predict the progression from NPDR into PDR.Purpose: To investigate the difference of MPC in patients with NPDR and PDR.Study design: Cross-sectional.Materials and methods: This study involved 71 DR patients. Preliminary data regarding the patients’ demographic characteristics, diabetes history, related diseases, medication history, and general eye examination were recorded. Fundus photographs were taken after dilating eyedrops and DR was graded by an ophthalmologist. The patients were grouped into NPDR and PDR. Mean platelet component was analyzed using the automatic hematology analyzer ADVIA 120.Results: Mean platelet component (MPC) was 26.69 g/dl (± 1.79) and 25.52 g/dl (± 1.20) in the NPDR and PDR group, respectively (p = 0.002), but was not clinically significant. In depth analysis into the DR grades differed significantly between mild NPDR and high-risk PDR (p = 0.015), and moderate NPDR and high-risk PDR (p = 0.024). Using our definition of mild DR (mild and moderate NPDR) and severe DR (high-risk and advanced PDR), there was a significant difference with mean MPC of 27.01 g/dl (± 1.64) and 25.31 g/dl (± 1.22), respectively (p = 0.001). The proportion of activated platelets was also higher in severe DR. Negative correlations were found between MPC with duration of DM (r = -0.333; p = 0.004) and MPC with systolic blood pressure (r = -0.241; p = 0.043).Conclusion: There was a significant difference in MPC between NPDR and PDR, but the results should be interpreted carefully. Further analysis between the mild and severe form of DR strengthened this finding.

Value of pharmacy services upon admission to an orthopedic surgery unit

Background In Lebanon, the role of the pharmacist remains underestimated in the medication reconciliation process, especially in surgical departments. This study aims to assess the impact of pharmacist-conducted medication reconciliation performed within 48 h of hospital admission to the orthopedic surgical department. Methods This was a prospective single-arm study conducted in a tertiary-care teaching hospital in Lebanon between October 2019 and April 2020. Participants were adult inpatients hospitalized for orthopedic surgeries with ≥ 1 outpatient medications. Properly trained pharmacy resident obtained the Best Possible Medication History (BPMH) and led the reconciliation process. The primary endpoint was the number of reconciliation errors (REs) identified. Descriptive statistics were used to report participants’ responses and relevant findings. Linear regression was performed with the number of REs as a continuous dependent variable using backward method. Results were assumed to be significant when p was < 0.05. Results The study included 100 patients with a mean age of 73.8 years, admitted for elective (54%) or emergency (46%) surgeries. Half of the study population had ≥ 5 home medications. The mean time for taking BPMH was around 8 min. A total of 110 REs were identified in 74 patient cases. The most common discrepancies consisted of medication omission (89.1%) and the most common medications involved were antihyperlipidemic agents. Twenty-four REs were judged as clinically significant, and four as serious. The most common interventions included the addition of a medication (71.9%). Most of the relayed interventions (84.5%) were accepted. The number of home medications was the only variable significantly associated with the number of REs (β 0.492; p < 0.001). Conclusion Pharmacy-led medication reconciliation upon admission to orthopedic surgery department can reduce reconciliation errors and improve medication safety. Trial registration Retrospectively registered in the Lebanon Clinical Trials Registry (LBCTR2020124680).

Importance of medication reconciliation in cancer patients

Cancer patients are a complex and vulnerable population whose medication history is often extensive. Medication reconciliations in this population are especially essential, since medication discrepancies can lead to dire outcomes. This commentary aims to describe the significance of conducting medication reconciliations in this often-forgotten patient population. We discuss additional clinical interventions that can arise during this process as well. Medication reconciliations provide the opportunity to identify and prevent drug–drug and herb–drug interactions. They also provide an opportunity to appropriately adjust chemotherapy dosing according to renal and hepatic function. Finally, reconciling medications can also provide an opportunity to identify and deprescribe inappropriate medications. While clinical impact appears evident in this landscape, evidence of economic impact is lacking. As more cancer patients are prescribed a combination of oral chemotherapies, intravenous chemotherapies and non-anticancer medications, future studies should evaluate the advantages of conducting medication reconciliations in these patient populations across multiple care settings.

Clinical trial emulation can identify new opportunities to enhance the regulation of drug safety in pregnancy.

From the perspective of most regulatory agencies, it is usually unethical to perform interventional clinical trials on pregnant people. While this policy recognizes the vulnerability of an expectant mother and unborn child, it has created a public health emergency for millions of pregnant patients through a dearth of robust safety data for many common drugs. To address this problem, we harnessed an enterprise collection of 2.8M electronic health records (EHRs) originally collected from routine primary care, leveraging the data linkage between mothers and their babies to create a surrogate for randomized, controlled drug trials in this population. To demonstrate the feasibility of our clinical trial emulation platform to stimulate new hypotheses for post-market drug surveillance, we identified 1,054 drugs historically prescribed to pregnant patients and developed a medication history-wide association study and follow-up evidence synthesis platform (leveraging expert clinician review and real-world data analysis) to test the effects of maternal exposure to these drugs on the incidence of neurodevelopmental defects in their children. Our results replicate known teratogenic risks and existing knowledge on drug structure-related teratogenic risks. Herein, we highlight 5 common drug classes that we believe warrant further assessment of their safety in pregnancy. We also discuss our efforts to develop a discovery-to-regulatory framework that could allow for pragmatic translation of our results to enhanced regulatory policy. Collectively, our work presents a simple approach to evaluating the utility of EHRs in guiding new regulatory review programs focused on improving the delicate equipoise of accuracy and ethics inherent to assessing drug safety in an extremely vulnerable patient population.

Long-term safety and disease control with ruxolitinib cream among patients with atopic dermatitis based on previous medication history: Pooled results from two phase 3 studies

N/A