• SVR Rates of Direct-Acting Antiviral Hepatitis C Therapies in Patients at a Specialty Pharmacy

      Mathews, Kelly; Mauro, Joseph; Dhaliwal, Sarina; College of Pharmacy, The University of Arizona (The University of Arizona., 2019)
      Specific Aims: To compare sustained virological response at 12 weeks after the end of therapy (SVR12) rates of direct acting antiviral (DAA) hepatitis C therapies in patients at a specialty pharmacy to SVR12 rates from recently published literature. To identify insurance coverage rates among different insurance payer types. Subjects: Patients that were at least 18 years or older, have a diagnosis of Hepatitis C, and had at least 1 DAA fill from Avella Specialty Pharmacy. Methods: A retrospective chart review was conducted utilizing data extracted from patient profiles who have filled a prescription at Avella Specialty Pharmacy for either Epclusa, Harvoni, Mavyret, Vosevi, or Zepatier during January 2017 to March 2018. Main Results: Of the 1,738 patients extracted for the review, 712 patients had SVR12 outcomes documented. The overall SVR12 rate of patients at Avella Specialty Pharmacy was not significantly different from published literature (97% vs 97%, p=0.96). Patients with genotype 2 at Avella Specialty Pharmacy achieved a total higher SVR12 rate when compared to published literature (100% vs 96%, p<0.05). Medicare had the highest coverage rates and Medicaid had the lowest coverage rates (56% and 16%, respectively). Conclusions: Our findings show that Avella Specialty Pharmacy can help patients obtain high cost medications through their insurance while maintaining SVR12 rates similar to those published in the literature. The services provided to patients by specialty pharmacies are essential to maintain high treatment outcomes and improve coverage rates.
    • Prescribing Habits of Citalopram at El Rio Health Center for Patients Older than 60 Years of Age

      Kennedy, Amy; Klein, Amanda; Chiles, Gavin; Hertzig, Hannah; Johnson-Bacon, Megan; Shahnooshi, David; College of Pharmacy, The University of Arizona (The University of Arizona., 2019)
      Specific Aims: To analyze current prescribing habits of citalopram in patients over 60 years of age and to identify concomitant use of cytochrome P450 2C19 (CYP2C19) inhibitors with citalopram at any dose. Subjects: El Rio Health patients that are greater than 60 years of age and are receiving citalopram Methods: A retrospective chart review was conducted to collect data on El Rio patients over 60 years of age that were prescribed citalopram. The citalopram dose and use of concomitant CYP2C19 inhibitors were recorded for these patients. Demographic data including age, gender, and race along with various labs such as EKG, QTC, liver function, kidney function, and PHQ-9 were also collected if available. Main Results: 45.1% vs. 23.5% were on concomitant CYP2C19 inhibitors with citalopram at doses less than 40 mg group versus with citalopram at doses greater than 40 mg respectively (p<0.001). Conclusions: In patients over 60 years old, there were a greater number prescribed citalopram at dose less than 40 mg than at doses greater than 40 mg, and there were also fewer patients concomitantly taking CYP2C19 inhibitors with citalopram at doses greater than 40 mg than those concomitantly taking CYP2C19 inhibitors with citalopram at doses less than 40 mg.
    • Acute Adverse Effects of Cannabis: A Perspective from Arizona’s Poison Control Centers

      Dudley, Steven; Sinchuri, Chandra; Chau, Dieu; Hoffman, Mark; Heydorn, Christian; College of Pharmacy, The University of Arizona (The University of Arizona., 2019)
      Specific Aims: The overall purpose of this study was to examine and describe some of the acute adverse effects of cannabis that have been reported in the state of Arizona in order to provide insights into potentially pertinent toxicities. Another aim was to examine the data for any correlation between age and side effects experienced. Methods: De-identifed data tables detailing case information for cannabis-related calls made to either of the two poison control centers in the state of Arizona in the year 2017 were prepared and analyzed. Data examined included age, gender, number of substances involved, and general descriptors of the side effects reported for each patient case. A chi-square with Yates’s correction was utilized to look for any association between age group and the different types of adverse effects reported. Main Results: A total of 82 poison control center cases were examined. Side effects involving the central nervous system, cardiac systems, and mental health were among the most commonly reported. No association was found between age and the occurrence of any particular type of adverse effect (p = 0.866). Conclusions: Though seemingly not dependent on the age of the user, our data may suggest that the use of cannabis can potentially contribute to a wide variety of acute adverse effects – most notably involving the central nervous system, cardiac systems, and mental health. However, as this study is lacking in generalizability, further research will need to be done in order to elucidate a more accurate side effect profile.
    • A Safety and Efficacy Meta-Analysis of Immune Checkpoint Inhibitors for Non-Small Cell Lung Cancer

      McBride, Ali; Abraham, Ivo; Abrego, Jordyn; Alvarez, Krizol; Howdeshell, Joseph; College of Pharmacy, The University of Arizona (The University of Arizona., 2019)
      Specific Aims: The objective of this study was to compare the median progression-free survival and safety profiles of the immune checkpoint inhibitors nivolumab, pembrolizumab, and atezolizumab in patients with non-small cell lung cancer. Other analyses included the incidence of any grade adverse event, any grade nausea, fatigue, and diarrhea. Methods: This meta-analysis included the original Phase II and Phase III clinical trials that lead to the approval of these agents. A screening tool was used to identify studies to be included, and a data extraction tool was utilized for data collection. One-way ANOVA and Chi-square tests were used to analyze the results. Main Results: Median progression-free survival was not equal between the three drugs (p=0.0007). Pembrolizumab provided the longest median progression-free survival of 9.6 months compared to both atezolizumab (3.1 months, p=0.029), and nivolumab (3.3 months, p=0.041). Despite its efficacy, pembrolizumab had a higher incidence of adverse events leading to discontinuation than both atezolizumab and nivolumab (p<0.00001). While there was not a significant difference in the incidence of any grade adverse events between pembrolizumab and atezolizumab (p=0.24), nivolumab showed significantly less incidence than the other drugs (p<0.00001). Conclusions: The results of this study suggest that nivolumab, pembrolizumab, and atezolizumab are not equally effective or safe. While pembrolizumab provided the longest median progression-free survival, it also had the highest rates of discontinuation due to adverse effects. These differences in efficacy and side effect profiles can aid oncologists in choosing the most appropriate agent for their patients with non-small cell lung cancer.
    • Effect of Rocuronium Versus Succinylcholine on Time to Neurosurgical Intervention in Patients with Intra-Cranial Hemorrhage

      Patanwala, Asad; Kamangar, Kianaz; College of Pharmacy, The University of Arizona (The University of Arizona., 2019)
      Specific Aims: To determine if patients with severe traumatic brain injury receiving a longer-acting neuromuscular blocking agent (rocuronium) in RSI lead to a delay in neurosurgical procedures compared to patients receiving a short-acting neuromuscular blocking agent (succinylcholine). Methods: This was a retrospective cohort study conducted in an academic ED in the United States. A list of patients who received RSI in the ED between the periods 1 Jan 2014 to 1 October 2017, was generated from an RSI database maintained by the department of emergency medicine. Data was collected from electronic medical records and entered into Research Electronic Data Capture (REDCap). The primary outcome variable was the time from RSI to neurosurgical procedure. Information collected included patient demographics, medications used, and clinical information about the head injury. Data regarding timing of RSI, neurosurgeon assessment, and subsequent neurosurgical procedure were also collected. Main Results: The median time from ED presentation to RSI was 18 (10-83) minutes with succinylcholine and 46 (16-133) minutes with rocuronium (p=0.187). The median time from RSI to neurosurgeon assessment was 64 (32-211) minutes with succinylcholine and 123 (34-165) minutes with rocuronium (p=0.950). Neurosurgeon assessment occurred >120 min after RSI in 38% (n=15) patients with succinylcholine and 50% (n=9) patients with rocuronium. The median time from RSI to neurosurgical procedure was 179 (93-390) minutes with succinylcholine and 155 (84-226) minutes with rocuronium (p=0.616). Conclusions: Patients with severe traumatic brain injury receiving rocuronium in RSI did not have a significantly longer time to neurosurgical procedure compared to patients receiving succinylcholine.
    • Drug-drug interaction between Protease inhibitors and statins and Proton pump inhibitors

      Malone, Daniel; Orido, Charles; McKinnon, Samantha; College of Pharmacy, The University of Arizona (The University of Arizona., 2019)
      Objective: The purpose of this article is to provide a systematic review of the pharmacokinetic and clinical data on drug-drug interactions between protease inhibitors (PIs) and statins, atazanavir and proton pump inhibitors (PPIs)and their clinical relevance. Methods: A literature search was performed using Medline, EMBASE and google scholar, abstracts from 1970 to 2019 of major conferences were searched and FDA drug information package inserts of the manufacturer of every currently available PI was looked at. All data was summarized and verified by at least two investigators. Results: A total of 246 references were identified, 8 of which were studies of pharmacokinetic and pharmacodynamics interactions between simvastatin, lovastatin and protease inhibitors and an additional 7 articles that provided pharmacokinetic of proton pump inhibitors and Atazanavir. Conclusions: Protease inhibitors increases the AUC and Cmax of simvastatin by approximately 500% and 517% respectively. Therefore, simvastatin and Lovastatin are not recommended for a co-administration with a protease inhibitor. Other statins such as rosuvastatin and pravastatin, can be used and are the main statins recommended. Atazanavir can be administered with PPIs but change of an acid reducing agent may be warranted, if possible. Providers should keep a close eye to those patients taking atazanavir and PPIs and consider a change to H2RA.
    • Measuring adherence trends among patients taking a 3-hydroxy-3-methylglutaryl-coenzyme-A (HMG-CoA) reductase inhibitor

      Boesen, Kevin; Bingham, Jennifer; Lowe, Ryan; Marzella, Franco; Welton, Mitchell; College of Pharmacy, The University of Arizona (The University of Arizona., 2019)
      Specific Aims: There are three specific aims for this project. 1) Determine if PDC rates in patients taking a statin medication differ between male and female patients. 2) Determine if PDC rates in patients taking a statin medication differ between patients with only one chronic condition versus those with more than one chronic condition. 3) Determine if PDC rates in patients taking a statin medication differ between type of statin therapy. Our working hypothesis for all three hypotheses is that there is a statistically significant difference between groups. Purpose: How many of your patients are not adherent to their statin regimen? Patients who are nonadherent to their 3-hydroxy-3-methylglutaryl-coenzyme-A reductase inhibitor therapy (statin) are at increased risk of uncontrolled cholesterol levels, cardiovascular events, and mortality. As patients are diagnosed with more disease states they are likely to be prescribed more medications for treatment. The study objective was to evaluate how the number of comorbidities affect medication adherence, measured via the Proportion of Days Covered. Additional analyses were conducted for adherence based on patient gender and by type of HMG-CoA reductase inhibitor. Methods: Data was originally collected by SinfoníaRx, a medication management technology and service company, as part of an internal quality improvement project. For this retrospective review, the data were deidentified by SinfoníaRx staff prior to providing it to the researchers. Variables in the de-identified data set included patient age, patient gender, Proportion of Days Covered, the number of chronic conditions for each patient, and the specific 3-hydroxy-3-methylglutaryl-coenzyme A reductase drug the patient was taking. Separate data sets were then created from the original data by filtering patients by gender, number of comorbidities, and specific drug. The gender analysis consisted of two groups (male and female) and a t-test was performed to analyze the average Proportion of Days Covered between the groups. An analysis of variance was performed to analyze the average Proportion of Days Covered. A Bonferonni post-hoc analysis was performed to measure significance between the groups. Results: A total of 55,345 patients were included in the analysis. Patients with multiple comorbidities were significantly more adherent according to their average Proportion of Days Covered (expressed as a percent) as follows: 0- (58.8%, P = <0.01), 1- (63.4%, P = <0.01), and 2-4- comorbidities (68.1%, P = <0.01). Men’s adherence rates were 68.13% and women’s adherent rates were 67.65%. Atorvastatin and the ezetimibe/simvastatin combination medications had significantly better adherence when compared individually to the other drugs included in the analysis. Conclusion: This study suggests that patients with more chronic conditions were more adherent to their medications than those with fewer or no chronic conditions. However, even the most adherent patients in this study still had Proportion of Days Covered values well below the recommended threshold. Future research is warranted to facilitate designing adherence program materials to help patients with fewer chronic conditions improve adherence to prescribed regimens.
    • Evaluation of Treatment Complexity and Initial Behavioral Health Screenings in Patients with Cystic Fibrosis

      Phan, Hanna; Celaya, Timothy; Faqeeri, Zohal; Lopez, Dania; Nguyen, Christen; College of Pharmacy, The University of Arizona (The University of Arizona., 2019)
      Purpose: The purpose of this study is to investigate the potential association between patient factors, including treatment complexity score (TCS), and initial behavioral health screening outcomes in patients with cystic fibrosis (CF). Introduction: CF, a multi-organ genetic disease, often results in time-consuming treatment regimens, frequent hospitalizations, and disease progression. High treatment burden may contribute to behavioral health complications that can negatively impacting health outcomes. Methods: This was a secondary analysis of de-identified data from a quality improvement initiative on implementing guideline recommended behavior health screenings in an accredited, CF Care Center in patients ages 12 years and older. TCS was calculated using previous method in literature and modified to account for other chronic medications for comorbidities as well as CFTR modulator use. Inclusion criteria was complete medication data and generalized anxiety disorder-7 (GAD-7) and/or patient health questionnaire-9 (PHQ-9) results. Data included demographics and medications at time of initial screening. Statistical analysis consisted of descriptive statistics including Wilcoxon Rank Sum, Chi square, and Fisher's Exact tests. Results: A significant difference was observed within the demographic as well as GAD-7 and PHQ-9 classification in respect to pre-existing comorbidities of anxiety and depression, respectively. Within the modified treatment complexity score (MTC) grouped by PHQ-9 and GAD-7 score classification, no significant differences were seen. Conclusion: No significant difference was observed in modified TCS between patients who screened moderate to severe in the depression and anxiety screenings. Multiple patient specific factors may contribute to positive screenings describing the complex nature of behavioral health.
    • Assessing Language Assist Program Usage in Retail Pharmacies Through An Online Survey Among AzPA Members

      Cooley, Janet; Allen, Hyrum; Grigorosita, Emanuel; Wright, Taylor; College of Pharmacy, The University of Arizona (The University of Arizona., 2019)
      Specific Aims: To find out if pharmacists use translation assist programs when counseling patients who have very limited ability to speak or understand English. Subjects: Pharmacists in Arizona who are employed at least part-time and work in a community setting. Methods: Surveys were distributed through the Arizona Pharmacists Association (AzPA) newsletter to community pharmacists. Participants were questioned about demographics including work environment, English as a first language, and gender. Other information collected included how busy the pharmacist’s store was, how many opportunities they had to use a language assist program, if their employer provided a language assist service, if they used the service, and what some reasons may be for not using a language assist service. Main Results: Surveys were complete by 58 pharmacists in Arizona. 52 of the 58 participants (90%) said that their employer provided a language assist program, but only half reported that they actually use it. The most common reason reported for not using a translation service was because they were “too busy or did not have enough time” (69%). No statistically significant results were found comparing translation service use between rural versus urban pharmacists, pharmacists with different script volumes, or the number of years a pharmacist has been working. Conclusion: Although more pharmacists were aware of translation services available than predicted, only half of the pharmacists reported using the service.
    • Metastatic Colorectal Cancer: A Systematic Review of Disease Manifestation and Response to Treatment in Right- vs Left-Sided Adenocarcinoma

      McBride, Ali; Belosludtsev, Paulina; College of Pharmacy, The University of Arizona (The University of Arizona., 2019)
      Metastatic colorectal cancer (mCRC) is a well-known and recognized disease. It is a heterogeneous, progressive, non-cutaneous, multi-stage example of hyperactive cellular dysfunction and genetic overexpression. It is widely documented as being the third most prolific form of cellular carcinogenesis and it accounts for approximately 90% of malignancy in tumors within the large bowel. In recent years, advances in clinical research have revealed that much of the diversity associated with the manifestation of colonic adenoma may be linked to the heterogeneous embryonic origins of the colonic landscape. For example, adenocarcinoma of the proximal (ascending) right-side of the colon, which develops embryologically from the midgut, typically presents with microsatellite instability and a higher frequency of BRAF mutations. In contrast, disease expression within the distal (descending) left-side of the colon, which shares nascent origins with the hindgut, is characterized by chromosomal instability and activation of the epidermal growth factor receptor (EGFR) pathway. As a result, these variances highlight an important relationship between site-specific embryology and disease etiology. It is believed that a heterogeneous approach to therapeutic treatment methodologies based upon the biogeography of the colonic landscape, may hold an important key to unlocking and advancing the overall efficacy of first-line therapies used in the treatment of metastatic colorectal cancer. SPECIFIC AIMS: The purpose of this project is to perform a systematic review of primary literature from studies where-in targeted anti-VEGF and anti-EGFR treatments were administered as first-line therapy to patient populations inclusive of right-sided and/or left-sided colorectal cancer in order to evaluate the efficacy of site-specific treatment on Overall Survival (OS), Objective Response (OR), and Progression-Free Survival (PFS) rates.
    • Investigating the Impact of a Mental Health Adherence Intervention on Mental Health Medication Adherence in Patients with Diabetes

      Bingham, Jennifer; Benson, Cody; Lee, Heather; Michael, Rianne; College of Pharmacy, The University of Arizona (The University of Arizona., 2019)
      Specific Aims: Evaluate the impact of targeted psychotropic medication adherence interventions by pharmacists on psychotropic medication adherence rates in patients with type 2 diabetes and determine whether patient-specific variables, such as age, gender, or type of psychotropic medication being taken, influence the degree of impact. Methods: Adherence, as indicated by proportion of days covered (PDC), was measured before and after face-to-face counseling by a community pharmacist. Pharmacists were alerted to counsel patients receiving Medicare Part D prescription coverage who were prescribed a psychotropic medication and exhibited a PDC of <85%. Data regarding PDC, age, gender, and type of psychotropic medication were analyzed for patients between 18 and 84 years of age with type 2 diabetes. Main Results: The data set contained 8,167 patients eligible for analysis, including 5,438 women (mean age=63.6 years, SD=11.5) and 2,729 men (mean age=61.6 years, SD=10.3). There was significant improvement in PDC after pharmacist intervention overall (mean PDC increase=13.5%, SD=20.2, p<0.01) and for each subgroup, with the exception of nefazodone (n=3, p=0.66). Patients 65 years and older showed the greatest improvement (PDC change=14.5, p<0.01), followed by patients aged 40-64 years (PDC change=12.5, p<0.01) and then 20-39 years (PDC change=9.1, p<0.01). Conclusions: Targeted face-to-face interventions by pharmacists significantly improved psychotropic medication adherence in adult patients with type 2 diabetes receiving Medicare Part D prescription coverage. Improvement was seen regardless of gender, age, or type of psychotropic medication, except nefazodone, and was greater with increasing age. The degree of improvement also varied among certain psychotropic medications.
    • Evaluation of immune-related adverse events with pembrolizumab for the treatment of advanced metastatic melanoma

      McBride, Ali; Albright, Jason; Briones, Kimberly; Smith, Eric; College of Pharmacy, The University of Arizona (The University of Arizona., 2019)
      Specific Aims: Immune checkpoint inhibitors (CPI) have made breakthrough therapeutic advances in oncology, but are associated with a unique spectrum of side effects. A thorough understanding of immune-related adverse events (irAEs) is vital in reducing mortality and morbidity from immunotherapy. The purpose of this study was to evaluate the irAE profile of pembrolizumab, a PD-1 inhibitor, in melanoma patients treated at The University of Arizona Cancer Center. Methods: We identified patients treated with pembrolizumab for advanced melanoma between 2011 and 2017. Demographics, treatment, irAEs, and hospitalization details were collected. IrAEs were graded using the Common Terminology Criteria for Adverse Events (CTCAE) v4.0. Results: Of the 64 patients included in this analysis, seven had unresectable stage III and 57 had stage IV melanoma. The median age was 67 with 43 patients (67.2%) being male. In total, 158 irAEs were reported, and 49 out of 64 (76.6%) patients had an irAE. 134 (84.8%) were grade 1 irAEs, 21 (13.3%) were grade 2, whereas grade 3 and 4 were 1.9%. Pruritus (20.9%) was the most common grade 1 to 2 irAE, followed by joint/muscle pain (12.7%) and diarrhea (12.0%). Conclusions: In general, treatment with pembrolizumab at our institution suggests a higher incidence of irAEs per patient compared to previous clinical trials: diarrhea (29.7% vs 14.4%, p=0.004), pruritus (51.6% vs 14.1%, p <0.00001), and rash (25% vs 13.4%, p=0.021), respectively. Most irAEs resolved with appropriate therapy or were self-limiting.
    • Patterns and Predictors of Off-Label Antipsychotic Use Among Older Adults with Dementia in Ambulatory Care Settings in the United States (US)

      Bhattacharjee, Sandipan; Abou-Eid, Michelle; College of Pharmacy, The University of Arizona (The University of Arizona., 2019)
      Specific Aims: To examine the patterns and predictors of off-label antipsychotic use among older adults with dementia in the ambulatory care settings in US. Methods: This was a retrospective, cross-sectional study using pooled data from the National Ambulatory Medical Care Survey (NAMCS) (2005-2015). The study sample consisted of ambulatory visits by older adults (age ≥ 65 years) with dementia who were prescribed off-label antipsychotic(s). Dementia was identified by using ICD-9-CM codes of 290.xx, 294.xx, or 331.xx or by examining use of cholinesterase inhibitors or memantine. Antipsychotics are approved for treating individuals with schizophrenia (ICD-9-CM: 2950x–2959x), bipolar disorder (ICD-9-CM: 2960x, 2961x, 2964x–2969x), Tourette syndrome (ICD-9-CM: 307.23), or Huntington’s disease (ICD-9-CM: 333.4). Patients with these co-occurring diseases were excluded from the final study sample. Predictors of off-label antipsychotic use were determined using multivariable logistic regression adjusting for individual-level factors. All analyses were adjusted for the complex survey design of NAMCS to obtain nationally representative estimates. Main Results: Over the 11-year study period, there over 74 million visits by older adults with dementia without conditions approved for treatment with an antipsychotic, among whom 6.2 million (8.37%) visits received an off-label antipsychotic prescription. Factors that were significantly associated with off-label antipsychotic use were age, gender, race/ethnicity, physician specialty, region, number of medications recorded at the sampled visit, and number of past visits. Conclusions: Considering over 8% of older adults with dementia received off-label antipsychotic, appropriate interventions are warranted to minimize off-label antipsychotic use in this vulnerable population.
    • Examining Persistence for Ibrance (palbociclib) for FDA Approved indication and dosing through a retrospective analysis

      Mathews, Kelly; Gianninoto, Jenna; Slack, Marion; Alanis, Elizabeth; Leon, Terra; Ochoa, Nicole; Tschida, Melanie; College of Pharmacy, The University of Arizona (The University of Arizona., 2019)
      Specific Aims: To determine whether receiving all medication therapy from a single pharmacy positively impacts medication adherence and lengthens duration of therapy in patients who are taking palbociclib for the treatment of HR+, HER2- metastatic breast cancer. Methods: In a retrospective cohort study, we analyzed 347 patients concurrently taking palbociclib and letrozole or fulvestrant. Patients with HR+, HER2- metastatic breast cancer currently on combination therapy of palbociclib and letrozole or fulvestrant filling at Avella Specialty Pharmacy between March 2016 to December 2017. Patients were divided into two groups characterized by those that filled both agents at Avella Specialty Pharmacy and those that only filled palbociclib at Avella and the other agent at a retail pharmacy. We compared the mean length of therapy, the PDC mean, and payor type between both patient groups. Primary outcome was the Proportion of Days Covered (PDC). Secondary outcomes included days on therapy and payor type. Main Results: Data analysis was conducted among the 347 patients (mean age = 69.37; SD = 11.40). Comparison of PDC mean resulted in no significant difference (SPP mean = 94.5%, SD = 0.11; Non-SPP mean = 95.06%, SD = 0.09; t-test p-value = 0.82/Mann-Whitney U test p-value = 0.76). Days on therapy presented no significant difference (SPP mean = 177.81, SD = 136.95; Non-SPP mean = 173.09, SD 157.69; t-test p-value= 0.83/Mann-Whitney U test p-value: 0.07). Comparison of payor type between patient groups had no significant difference (p-value = 0.13). Conclusions: Adherence and length of therapy for patients filling both agents at Avella were similar to those filling the second agent at an alternative retail pharmacy.
    • Assessing Venous Thromboembolism Prophylaxis Prescribing Patterns in Older Adults Undergoing Hip Fracture Surgery

      Campbell, Ashley; Droopad, Debra; Shah, Isha; Shepard, David; College of Pharmacy, The University of Arizona (The University of Arizona., 2019)
      Objectives: To explore the prescribing practices of venous thromboembolism (VTE) prophylaxis following hip fracture surgery (HFS). Subjects: geriatric patients over 65 requiring VTE prophylaxis post hip fracture surgery. Methods: Retrospective chart reviews were conducted using the electronic health record. Information obtained from the eligible patient’s chart included the anticoagulant for VTE prophylaxis, dose, duration, and the occurrence of post-surgical complications (e.g.: deep vein thrombosis [DVT], pulmonary embolism [PE], bleeding events). Main Results: 28 eligible patients were analyzed (mean age = 82.3; SD= 7.2; 61% female) with the most common fracture being femoral neck fracture repaired by hemiarthroplasty (61%). Upon discharge, 68% of patients were on enoxaparin (9 on 40 mg daily, 7 on 30 mg daily, 3 on 30 mg twice daily); 29% on aspirin (3 on 81 mg daily, 4 on 81 mg twice daily, 1 on 325 mg daily); and 4% on warfarin 1 mg daily. Within 30 days of HFS, 2 patients returned with a hematoma (discharged on twice daily aspirin 81 mg) and one with a DVT (on appropriately dosed enoxaparin). Within 60 days, another patient presented with a DVT (on aspirin 81 mg daily), and at 90 days, one patient presented with intracranial hemorrhage (on appropriately dosed enoxaparin). Conclusions: Prescribing practices of VTE prophylaxis vary among different providers with different dosing regimens, especially aspirin. Due to a low event rate, the clinical significance of these effects would be best interpreted through larger clinical trials over an extended duration, allowing for greater power.
    • Management Strategies and Outcomes for Migraine within Community Dwelling Adults: A Systematic Review

      Slack, Marion; Martin, Jennifer; Tien, Tan; Marupuru, Srujitha; College of Pharmacy, The University of Arizona (The University of Arizona., 2019)
      Specific Aims: To describe the pharmacological and non-pharmacological strategies that community dwelling adults use to manage migraine. Methods: PubMed, Embase, Cochrane Library, Web of Science, and Scopus were searched for studies of self-reported migraine management strategies by community dwelling adults aged 18-80 years published in English after 1989. Citation searches and reference list searches for the identified studies also were conducted. Study selection, data extraction, and quality assessment were completed independently by multiple reviewers and differences resolved by consensus. Data were analyzed by constructing summary tables of study characteristics and of the management strategies identified. Main Results: A total of 7757 studies were identified, of which 14 met inclusion criteria. The studies were conducted in eight different countries. The sample size varied from 138 to 3065. The mean age of participants ranged from 35 to 80 years. The mean percent of females was 52. Out of the 14 studies, 9 used self-administered questionnaires and 5 used interviews/telephonic methods. The primary method of treatment in this population was medications, primarily triptans (8-59%), NSAIDS (14.7-59%) and ergotamine’s (0.3-21. 8%). Opioid usage was reported in 5 studies (used by 1-8. 7% of participants). Non-pharmacological strategies for migraine management were reported in only 4 studies. Overall satisfaction with treatment varied from 31.2 to 93.2%. Conclusions: Medications, primarily triptans and NSAIDS, were the primary pharmacological management strategies used by migraineurs. Use of opioids and other non-pharmacological strategies was low. Satisfaction with migraine management varied widely.
    • Fumarate Mediates a Chronic Proliferative Signal in Fumarate Hydratase-Inactivated Cancer Cells by Increasing Transcription and Translation of Ferritin Genes

      Ooi, Aikseng; Duckworth, Spencer; Liang, Benjamin; College of Pharmacy, The University of Arizona (The University of Arizona., 2019)
      Germ line mutations of the gene encoding the tricarboxylic acid (TCA) cycle enzyme fumarate hydratase (FH) cause a hereditary cancer syndrome known as hereditary leiomyomatosis and renal cell cancer (HLRCC). HLRCC-associated tumors harbor biallelic FH inactivation that results in the accumulation of the TCA cycle metabolite fumarate. Although it is known that fumarate accumulation can alter cellular signaling, if and how fumarate confers a growth advantage remain unclear. Here we show that fumarate accumulation confers a chronic proliferative signal by disrupting cellular iron signaling. Specifically, fumarate covalently modifies cysteine residues on iron regulatory protein 2 (IRP2), rendering it unable to repress ferritin mRNA translation. Simultaneously, fumarate increases ferritin gene transcription by activating the NRF2 (nuclear factor [erythroid-derived 2]-like 2) transcription factor. In turn, in- creased ferritin protein levels promote the expression of the promitotic transcription factor FOXM1 (Forkhead box protein M1). Consistently, clinical HLRCC tissues showed increased expression levels of both FOXM1 and its proliferation-associated target genes. This finding demonstrates how FH inactivation can endow cells with a growth advantage. Specific Aims 1. Show biallelic fumarate hydratase (FH) inactivation results in fumarate accumulation. We currently hypothesize FH inactivation will result in an inactive enzyme that cannot process fumarate. 2. Determine if and how fumarate accumulation endows cells with a chronic proliferative signal. We hypothesize that fumarate accumulation disrupts cellular iron signaling resulting in a chronic proliferative signal. Main Result - Fumarate accumulation confers a chronic proliferative signal in HLRCC cells. Conclusion - FH inactivation disrupts cellular iron signaling and induces a chronic proliferative phenotype, providing a mechanistic explanation for how the inactivation of FH can give rise to a fundamental cancer hallmark.
    • Self-reported Management of Back Pain by Community Dwelling Adults: A Systematic Review

      Slack, Marion; Martin, Jennifer; Azadbakht, Mostafa; Rahim, Rasoul; College of Pharmacy, The University of Arizona (The University of Arizona., 2019)
      Purpose: The purpose of this systematic review is to identify strategies that community dwelling adults use to manage chronic back pain. Methods: Studies were eligible for inclusion if the study participants were at least 18 years of age, and currently suffering from back pain and living in the community. Excluded were reports on individuals who were institutionalized. The articles had to be written in English language. We searched Pubmed, Embase, and conducted citation searches on identified articles. Two researchers independently reviewed studies for inclusion, and extracted data from identified studies. Any differences were resolved by consensus. Data were extracted on strategies used to manage pain and outcomes. Data were analyzed by constructing tables to report types of strategies used and outcomes. Main Results: A total of 1929 study reports were identified; 9 were included in the systematic review. The primary strategy to manage back pain was using medications. 5 studies reported the use of opioids. All studies except one reported the use of anti-inflammatories. Studies also reported the use of psychological strategies (e.g. coping strategies), physical strategies (e.g. exercise), and remedies (e.g. rest). Most studies were cross sectional, participants were 29-49 percent male, average age (31-66). All studies were of community dwelling adults. Conclusions: Medication was the primary strategy used to manage back pain. Opioids, and anti-inflammatories were the most common classes of medications. The most commonly reported non-medication strategy were physical strategies. Only limited information was provided on all the other strategies.
    • Transition of dose-adjusted EPOCH therapy into the outpatient healthcare setting, quality and cost considerations

      McBride, Ali; Yiu, Kelly; College of Pharmacy, The University of Arizona (The University of Arizona., 2019)
      Specific Aims: To determine if outpatient administration of DA-EPOCH +/- R chemotherapy is associated with increased efficacy, cost effectiveness, or increased patient risk for developing adverse events when compared with inpatient administration of the same regimen. Subjects: Adults receiving EPOCH-based regimens at Banner UMC-Tucson and associated clinics. Methods: A single-center, institutional review board-approved retrospective study was conducted for adults receiving EPOCH-based regimens. Data were collected by chart review for each patient. Descriptive statistics were utilized for analysis. Main Results: A total of 35 patients received 137 cycles of an EPOCH-containing regimen (17 [12.4%] inpatient), 55 [40.1%] outpatient, and 66 [48.2%] hybrid inpatient and outpatient). Two inpatient cycles (11.8%), 11 outpatient cycles (20%), and 10 hybrid cycles (15.15%) resulted in admissions for neutropenia. Six inpatient cycles were delayed (35.3%) for disease-related procedures and one (5.9%) was delayed for low blood counts. Five (9.1%) outpatient cycles were delayed due to logistics (i.e. insurance, scheduling errors) and two (3.6%) outpatient cycles were delayed due to disease-related adverse events (bowel obstruction, chest pain). Transitioning EPOCH to the outpatient setting decreased overall costs for hospital stays by $19,792 per cycle with an overall cost savings to the health-system of 1,114,992 dollars with 432 bed days saved. Conclusions: EPOCH-containing regimens can be safely transitioned into the outpatient setting, side effects can be monitored and outcomes optimized, to better adapt treatment strategies for individualized patient therapies. As new healthcare payment models are developed, outpatient treatments allow for adaptive financial options both for the payor and the patient.
    • Analysis of Cost Implications and Potential Adverse Events Prevented by Interventions of an Internal Medicine Pharmacist

      O’Connell, Colleen; Harding, Marcus; Chang, Shan Tzu; Stenquist, Haley; College of Pharmacy, The University of Arizona (The University of Arizona., 2019)
      Specific Aims: Duties conducted by clinical pharmacists aid patients in side effect prevention and have numerous cost benefits for health systems. A systematic manner of quantifying these tasks accomplished would adequately sum and describe cost-savings and preventions of adverse events within the hospital setting. The purpose of this study is to perform a cost benefit analysis and analyze cost implications and potential adverse drug events prevented through the interventions conducted by an internal medicine pharmacist. Methods: This study utilized a retrospective cohort design using data extracted from patients’ charts. The data was retrieved from patient charts at Tucson Medical Center using the EPIC computer system during a 3-month time span. Pharmacists on the adult medicine unit were educated on how to separately document and describe each type of clinical intervention with the option of selecting from twenty headings and four subheadings created by an EPIC system specialist. The rates of adverse effects and cost savings from literature evaluation were applied to each correlating intervention and medication as documented by the pharmacist. Main Results: These adult medicine pharmacists cumulatively made a total of 1182 interventions during a three-month time period. A total cost benefit of greater than $150,000 was identified from the analysis with consideration of pharmacist average salary over a 3-month period. This study estimated 150 adverse effects were prevented with the various tasks accomplished by clinical pharmacists. Conclusions: Decentralized clinical pharmacists on the adult medical unit promote patient safety and reduce overall cost through the avoidance of potential adverse drug events and drug optimization.