Evaluation of a Conservative Pharmacist-led U-500R Insulin Management Protocol in the Primary Care Setting

Objective The objective of this quality assurance study is to evaluate the impact of a conservative, pharmacist-led, U-500R insulin management protocol on diabetes control (A1c) and total daily dosage requirements between August 2016 and August 2018. Methods This was a retrospective chart review of adult patients, aged 18 to 79, with type 2 diabetes and managed with insulin, at 2 federally qualified healthcare clinics in Denver, Colorado. To determine if our conservative pharmacist-led U-500R insulin management protocol impacted efficacy and total daily dosage requirements when converting patients from U-100 to U-500R insulin, we compared the most effective dose of U-500R (defined as the total daily dose (TDD) of U-500R insulin at A1c goal or the lowest tolerated A1c) to the baseline A1c and TDD of U-100 insulin at time of conversion. Results Following conversion of U-100 to U-500R insulin, patients required an average of 21 fewer units of insulin with U-500R than U-100 and achieved an average A1c of 7.2% which reflected a reduction of 3.5 points from baseline. Five patients (62.5%) achieved A1c goal per ADA guidelines, and all patients achieved at least a 1.7 point reduction in A1c, with 1 patient achieving a 6.7 point reduction. Two patients (25%) were still in the process of U-500R titration at the time of data collection, and 1 patient (12.5%) did not achieve goal A1c while under pharmacy management at these clinics. Four of the five patients who achieved A1c goal did so with an overall reduction in total daily insulin dose (average of 57.5 units less than original U-100 dose) resulting in an average A1c decrease of 3.6 points.

The influence of inhaled corticosteroids on asthma control test in smokers and non-smokers with asthma

Smoking in asthmatics is responsible for the worsening of asthma symptoms, more frequent asthma exacerbations and hospitalizations and lowered quality of life. In smoking asthmatics the designated doses of the inhaled corticosteroid treatment are usually insufficient to accomplish total asthma control. Out of 54 screened adult patients up to 50 years old with mild asthma, 38 were involved in the study. They were divided in two groups: smokers and non-smokers. They received a total daily dosage of 500 µg of inhaled fluticasone propionate. A rescue medication, a short-acting ß2 agonist (salbutamol) in a dosage of 0.1 mg/per inhaled dose, was used when needed. Asthma was diagnosed by a positive metacholine provocation test and/or a positive bronchodilatator response. An asthma control test i.e. the ACT-TM questionnaire was performed before the beginning of the study and 6 weeks after the treatment with fluticasone propionate of the previous corticosteroid-naive patients. A statistically positive response (p<0.05) was reached in favor of non-smoking asthmatics. It can be concluded that ACT is a reliable tool to assess the effect of the topical corticosteroid treatment in non-smoking and smoking asthmatics. An achievement of better asthma control could be expected among both of the examined groups, but the effect of the intervention in the therapy is estimated to be more expressed within the group of asthmatic non-smokers. In smoking asthmatics there is a need for other therapeutic modalities such as increasing the dosage of inhaled corticosteroids, usage of combination therapy and/or adding low doses of aminophylline.

Praziquantel in the cerebrospinal fluid in neurocysticercosis

In 10 patients with neurocysticercosis (NC), an assessment was made of the praziquantel (PZQ) concentration in the cerebrospinal fluid (CSF), in non-deproteinized serum and in protein-free serum: before administration of the drug and the 1st., 7th. and 21st. days of oral administration (50mg/kg/day during 21 days). Samples of CSF and blood were collected three hours after the last administration of the daily total dosage, on the 1st. and 21st days; and from 2 to 6 hours after drug administration on the 7th. day. The total daily dosage was distributed into three equal parts of 1/3 each, with a 4 hours' interval between intakes, except in the last 5 cases, who on the 21st. day only were given the total daily dosage on a single administration. Results have shown dispersion in serum concentrations, which are similar to those seen in normal subjects as recorded in literature. There is a correlation between PZQ levels in the CSF and in the serum, the latter being very close to those found in protein-free serum fraction. The statistical treatment of results allowed the following considerations: PZQ concentrations in the CSF and in the protein free serum are in balance from the pharmacodynamic standpoint on the first day; this balance is maintained up to the 21st. day although at different levels from those seen on the 7th. day; on the 21st. day PZQ contents in CSF goes back to its similar values as recorded on the 1st. day, and this suggests that the participation of drug interaction factors has been reduced to non-significant levels. However, several factors can influence PZQ concentration in CSF, as absorption rate, liver first-pass effect and blood-brain barrier changes, and individual dose should be established for each patient based on drug concentration monitoring in the serum and/or in the CSF.

Twice-Daily Propranolol Treatment for Hypertension

During maintenance therapy the anti-hypertensive action of propranolol depends on total daily dosage. A within-patient cross-over study showed that the drug is equally effective when given twice or four times daily, although satisfactory blood pressure control was achieved slightly sooner with four times daily dosing.