No abstract

A drug-drug interaction (DDI) is a pharmacokinetic or pharmacological influence of 1 medication on another that differs from the known or anticipated effects of each agent alone.1 A DDI may result in a change in either drug efficacy or drug toxicity for 1 or both of the interacting medications.2 Pharmacokinetic DDIs result in altered absorption, distribution, metabolism, or excretion of a medication. A pharmacodynamic DDI occurs when 1 medication modifies the pharmacological effect of another in an additive, a synergistic, or an antagonistic fashion.It is estimated that ≈2.8% of hospital admissions occur as a direct result of DDIs. 3 However, the actual incidence of hospitalization secondary to clinically significant DDIs is likely to be highly underestimated because medication-related issues are more commonly reported as adverse drug reactions. Complex underlying disease states also may make recognizing a DDI more challenging, further contributing to a lower reported incidence. The overall clinical impact of a DDI can range from mild to life-threatening. Therefore, not all DDIs require a modification in therapy. The variability in the clinical significance of a DDI depends on both medication-specific and patient-specific factors. Medication-specific factors include the individual pharmacokinetic characteristics of each medication implicated in the DDI (eg, binding affinity, half-life [t 1/2 ]), dose of the medications, serum concentrations, timing and sequence of administration, and duration of therapy. Patient-specific factors include age, sex, lifestyle, genetic polymorphisms causing differences in enzyme expression or activity, and disease impairment affecting drug metabolism (eg, hepatic or renal impairment, cardiac failure) or predisposition to differences in efficacy or safety (eg, statin intolerance in patients with a history of myopathy). Clinically significant DDIs are usually preventable. To optimize patient safety, healthcare providers must have an understanding of the mechanisms, magnitude, and potential consequences of any given DDI. Interpreting this information will assist clinicians in the safe prescribing of medications and permits careful consideration of the benefits and risks of concomitant medications.Statins reduce morbidity and mortality in patients with known atherosclerotic cardiovascular disease (ASCVD) and in many primary prevention patients.4-9 Current guidelines recommend high-intensity statin therapy in all patients with ASCVD age ≤75 years and moderate-to high-intensity statin therapy in patients with ASCVD and age >75 years, diabetes mellitus, and familial hypercholesterolemia and in primary prevention patients with 10-year ASCVD risk ≥7.5%.10 Given the important role of statins in patients with ASCVD and those at high ASCVD risk, combination therapy with statins and other cardiovascular medications is highly likely, and potentially significant DDIs must be considered in patients treated with statins.Another important aspect of prescribing medications in combination is evalu...

Burnout is high among health care professionals. In physicians, burnout is linked to suboptimal well-being and patient care, but the overall landscape of pharmacist burnout is unknown. Synthesis of available data regarding pharmacist burnout is needed to better understand its effects on well-being and professional practice. This systematic review sought to determine the prevalence and intensity of burnout in pharmacists. The aim of the study was the systematic review of articles on pharmacist burnout. PubMed, Embase, Cochrane Central Register of Controlled Trials, and Psy-cINFO were searched for articles through February 13, 2019. Search strategies combined terms for pharmacists and burnout (including job satisfaction, stress, and resilience). The primary outcome was the proportion of pharmacists who met criteria for burnout. Secondary outcomes included the mean scores for Maslach Burnout Inventory (MBI) subscales, difference between pharmacist practice settings, and factors contributing to burnout. Raw scores and threshold proportions were pooled using a Hartung-Knapp random-effects model. Five articles reported the proportion of high emotional exhaustion (EE) and depersonalization (DP) and low personal accomplishment (PA), and nine articles reported individual MBI subscale scores, which were included for quantitative analysis. The proportion values of pharmacists with MBI subscale scores consistent with burnout were 41% (95% CI 27%-54%), 20% (95% CI 7%-32%), and 32% (95% 14%-50%) for high EE, high DP, and low PA, respectively. Mean MBI subscales scores were 23.53 (95% CI 21.68-25.39), 7.07 (95% CI 6.22-7.92), and 36.51 (95% CI 34.34-38.67) for EE, DP, and PA, respectively.Substantial heterogeneity was observed. The burnout prevalence among pharmacists is lower than previously reported, but notable. The average MBI subscale scores for high EE or DP or low PA in pharmacists did not meet criteria for burnout. K E Y W O R D S burnout, depersonalization, occupational health, pharmacists, pharmacy Burnout is a work-related syndrome defined by high emotional exhaustion and depersonalization, and a low sense of personal accomplishment. 1 In health care professionals, some of the factors contributing to burnout include a rapidly changing industry, declining reimbursement for services, increased clerical and documentation needs, and the emotionally intense role of patient care. 2 These

These findings suggest that using CYP2C19 genotype to guide P2Y12 inhibitor selection is feasible. Original submitted 27 October 2014; revision submitted 19 December 2014.

Nonsteroidal antiinflammatory drugs (NSAIDs) are used in the management of a variety of conditions, but their prevalence is likely underreported as a result of widespread availability and the perception that nonprescription therapies are unnecessary to report during medication history taking. However, NSAIDs are associated with a number of adverse effects, especially in patients with cardiovascular disease (CVD). Patients with CVD and comorbidities for which NSAIDs may provide symptomatic relief (e.g., osteoarthritis, rheumatoid arthritis) tend to be older, which places them at greater risk of harm. For these reasons, the use of NSAIDs in patients with CVD is a significant public health concern. An understanding of the risks associated with NSAIDs is critical for clinicians across practice settings. In this review, we detail the safety of NSAIDs in patients with CVD, provide recommendations on their use in specific disease states, and discuss therapeutic alternatives.

Argatroban was used as a purge solution anticoagulant in a patient with an Impella pVAD and found to be a safe and effective alternative to heparin.

Objectives. To characterize anticoagulation practices with the Impella percutaneous ventricular assist device (pVAD). Background. Managing anticoagulation in patients being supported by the Impella pVAD is made challenging by several unique features of the device. These include the release of a dextrose-based purge solution containing unfractionated heparin (UFH), the need to concurrently administer systemic anticoagulation with intravenous UFH, and the lack of an alternative strategy in patients with contraindications to UFH. Methods. To characterize anticoagulation practices with the Impella pVAD, we conducted a survey of centers in the United States performing a high volume of Impella cases, which we defined as > 1 per month. Centers were contacted via email or phone and individuals who agreed to participate were provided with a link to complete the survey online. The primary measures of interest were variations in practice across centers and variations from the manufacturer’s recommendations. Results. Practices varied considerably among respondents (65 of 182 centers, or 35.7%) and often diverged from manufacturer recommendations. Approximately half of centers (52.4%) reported using a UFH concentration of 50 units/mL in the purge solution, whereas most of the remaining centers (41.3%) reported using lower concentrations. Strategies for the initiation and adjustment of systemic therapy also varied, as did practices for routinely monitoring for hemolysis. Nearly one-fifth of centers (16.7%) had not developed an alternative strategy for the purge solution in patients with contraindications to UFH. Most centers (58.4%) reported using argatroban or bivalirudin in this scenario, a strategy that diverges from the manufacturer’s recommendations. Conclusions. Given these findings, studies to determine a systematic approach to anticoagulation with the Impella device are warranted.

Objective. To characterize leadership definitions, competencies, and assessment methods used in pharmacy education, based on a systematic review of the literature. Findings. After undergoing title, abstract, and full-text review, 44 (10%) of 441 articles identified in the initial search were included in this report. Leadership or an aspect of leadership was defined in 37 (84%) articles, and specific leadership competencies were listed or described in 40 (91%) articles. The most common definitions of leadership involved motivating others toward the achievement of a specific goal and leading organizational change. Definitions of leadership in some articles required that individuals hold a formal leadership position whereas others did not. Only two leadership competencies were related to specific areas of knowledge. Most of the competencies identified were interpersonal and self-management skills. In terms of assessment, only one (2.3%) article assessed leadership effectiveness, and none assessed leadership development. Of the remaining 24 (55%) articles that included some type of assessment, most involved behavioral-based tools assessing individual attributes conceptually related to leadership (eg, strengths, emotional intelligence), or selfassessments regarding whether learning objectives in a leadership course had been met. Summary. Definitions for leadership in pharmacy varied considerably, as did leadership competencies. Most conceptualizations of leadership resembled a combination of established approaches rather than being grounded in a specific theory. If leadership development is to remain a focus within accreditation standards for Doctor of Pharmacy education, a consistent framework for operationalizing it is needed.