Antipsychotic‐Induced Hyperprolactinemia

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/90238/1/phco.29.1.64.pd

Combination Therapy with Monoamine Oxidase Inhibitors and Other Antidepressants or Stimulants: Strategies for the Management of Treatment‐Resistant Depression

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/111275/1/phar1576.pd

Procarbazine and antidepressants: a retrospective review of the risk of serotonin toxicity

Background Procarbazine is an anticancer agent that also inhibits monoamine oxidase, an enzyme responsible for the metabolism of various catecholamines, including serotonin. Methods A retrospective chart review of lymphoma patients who were treated with both procarbazine and an antidepressant, as well as procarbazine alone, was performed to determine if signs and symptoms of serotonin toxicity were present. Results A total of 65 patients received procarbazine between 2004 and 2010 and were eligible to be included in the study. Twenty‐six of these patients received an antidepressant in combination with procarbazine, with selective serotonin reuptake inhibitors being the most common type of antidepressant. No patients in the study were diagnosed with serotonin toxicity, nor did any meet Hunter's diagnostic criteria for serotonin toxicity. Diarrhea, tremor, and shivering were the symptoms from Sternbach's criteria that were further analyzed, with diarrhea occurring 8.54% of the time, tremor occurring 5.53% of the time, and shivering occurring 2.51% of the time in patients who received an antidepressant with their procarbazine. Despite these symptoms, the diagnosis of serotonin toxicity according to Sternbach's criteria was determined to be unlikely. Conclusions In this small sample of patients treated with procarbazine plus an antidepressant (most typically SSRIs), there were no reports of serotonin toxicity, nor did any patients demonstrate symptoms consistent with serotonin toxicity. The authors urge clinicians to ensure depression is adequately managed in cancer patients who are undergoing procarbazine therapy, starting with typical first‐line antidepressant agents. Copyright © 2013 John Wiley & Sons, Ltd.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/102071/1/pon3378.pd

Using the Plan-Do-Study-Act (PDSA) Model for Continuous Quality Improvement of an Established Simulated Patient Program

Objective: To describe the use of a continuous quality improvement process for strengthening our simulated patient (SP) program and the initial steps that have been implemented.  Innovation: A workgroup that included five clinical faculty with significant experience working with SPs and a strong interest in improving the SP program was developed.  The Plan-Do-Study-Act model was used as it allowed for incremental quality improvement changes, in order to ensure a high-quality SP program designed to optimize student learning.  Data were gathered from students, SPs, and faculty. Opportunities for improvement were prioritized based on anticipated benefits and available resources.  Changes related to planning, implementation, and evaluation and feedback have been executed. Critical Analysis: Changes related to planning that were implemented included developing handbooks for SPs, faculty, and graduate student instructors, as well as material for students in order to better describe the program.  SPs are now referred to as “simulated” as opposed to “standardized” as part of a broader effort to clarify the purpose of SP interactions to students.  Streamlined rubrics have been piloted, including electronic rubrics for first year students.  SPs are being trained on fewer cases, in order to improve the training program.  When possible, activities now take place in one large classroom instead of many small classrooms to improve oversight.  Finally, additional feedback has been obtained from SPs via a retreat.  These changes have been well received by students, SPs, and faculty.    Next Steps: The collection of this data and initial quality improvement changes provided a basis for hiring a full-time employee who will: dedicate 50% of their time to programmatic assessment of the SP program, support faculty with logistics and training, and be the face of our program to the students and SPs. Further, formal quantitative and qualitative assessment of the SP program has begun.   Type:  Not

Psychotropic stewardship: Advancing patient care

Board Certified Psychiatric Pharmacists (BCPPs) practice in a variety of inpatient and outpatient health care settings as part of collaborative, multidisciplinary teams. The American Association of Psychiatric Pharmacists (AAPP) has promoted the expansion of psychiatric pharmacy through the development of psychotropic stewardship programs (PSPs). Based on the standards developed during the creation and expansion of antimicrobial stewardship programs, psychotropic stewardship promotes the safe and appropriate use of psychotropic medications. AAPP envisions every patient with a psychiatric diagnosis will have their medication treatment plan reviewed, optimized, and managed by a psychotropic stewardship team with a psychiatric pharmacist as a co-leader. Because of variations in practice site resources, patient populations, and provider collaboration, the creation and implementation of PSPs should be based on site-specific needs and opportunities. Initial patient identification could prioritize those prescribed multiple medications, high-risk psychotropics, or comorbid medical diagnoses. However, every patient prescribed a psychotropic medication should have the opportunity to work with a PSP. Incremental implementation may be required during the planning stages of stewardship teams. Use of clinical practice-related core outcomes will allow for the optimization of program resources, increased recognition, and improved patient outcomes. PSPs should be patient-focused and integrate patients' preferences and access to recommended treatment options. The eventual goal of PSP implementation is official recognition by key regulatory agencies as a standard of care for patients who receive a diagnosis of a psychiatric or substance use disorder

Opportunities for pharmacists to impact student health on college campuses

Literature regarding college student health has documented inadequate education and treatment of certain conditions such as mental health, preventive care, and sexual and reproductive health services. While some health services are available for students on campus, evidence suggests many at‐risk students do not utilize these services. Pharmacists are well‐suited to provide these services to college students, although there is a paucity of published data on the impact and outcomes of pharmacist intervention(s). This paper establishes the need for health interventions in college students, describes evidence supporting the role of a pharmacist on college campuses, and explores opportunities for pharmacists to address these unmet needs. A PubMed search was conducted for studies on college student health and services involving pharmacists using search terms encompassing college students and health‐related keywords. Studies written in English were considered and references from searched studies were manually reviewed for inclusion. When available, studies regarding pharmacist‐specific interventions on college health issues were included. Pharmacists can play a critical role in the treatment and management of psychiatric illnesses on college campuses. Data supporting psychiatric pharmacist recommendations are available. Further, pharmacists have shown interest and patient acceptance when providing sexual and reproductive services, including pharmacist‐provided prescription contraceptive products and preventive health services. Pharmacists can also influence preventive care practices on college campuses through health education including opioid use disorder, preventing overdose, and providing immunizations. While data demonstrate the positive impact pharmacists have on college students related to mental health, preventive health, and sexual health and reproductive services, available evidence is somewhat limited. However, ample opportunities exist to expand this impact. To more clearly and consistently demonstrate their impact on the college student population, pharmacists providing these services should be strongly encouraged to publish their work.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/168467/1/jac51433_am.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/168467/2/jac51433.pd

Warfarin Drug Interactions: Strategies to Minimize Adverse Drug Events The Journal for Nurse Practitioners -JNP 507

FN is a 75-year-old white woman with a past medical history significant for atrial fibrillation, transient ischemic attacks (TIA) , ABSTRACT Warfarin is an oral anticoagulant that requires international normalized ratio (INR) monitoring to assess its safety and efficacy and to facilitate dosage adjustments. It is metabolized primarily by CYP2C9 and has a narrow therapeutic index. Warfarin is prone to drug interactions, given its pharmacokinetic and pharmacodynamic properties. Changes in concomitant medications can cause INR fluctuations, particularly if medications are cytochrome P450 inhibitors or inducers. The unpredictability of the extent and duration of an interaction's effect make it challenging to manage, as represented in this case report. Providers are encouraged to adopt strategies to identify potential drug interactions and minimize the risks of adverse outcomes

The effect of a computerized best practice alert system in an outpatient setting on metabolic monitoring in patients on second‐generation antipsychotics

What is known and objectiveMetabolic syndrome is a well‐documented adverse effect of second‐generation antipsychotics (SGAs). Patients with metabolic syndrome are at an increased risk of potentially fatal cardiovascular events, including myocardial infarction and stroke. This elevated risk prompted the creation of a national guideline on metabolic monitoring for patients on SGAs in 2004. However, monitoring practices remained low at our clinic. To address this concern, a clinical decision support system was developed to alert providers of monitoring requirements. The purpose of this study is to determine the effect of the best practice alert (BPA), and to assess the impact of provider and patient characteristics on metabolic laboratory (lab) order rates.MethodsA retrospective chart review was conducted at a large outpatient psychiatric clinic. Data were collected from all adult patients who were prescribed an SGA and triggered the BPA (indicating lab monitoring is needed for the patient). Data collection included a variety of patient, provider and alert variables. The primary outcome was a composite of fasting blood glucose (FBG), haemoglobin A1c (HbA1c) and/or fasting lipid panel order rates. Secondary outcomes included the rate of valid response, which considered appropriate reasons for not ordering labs (ie monitoring already completed during recent primary care visit), as well as order rates of individual labs.Results and DiscussionData from 1112 patients were collected and analysed. Patients with a thought disorder diagnosis had significantly more labs ordered than those without. No other patient factors affected order rates. Resident psychiatrists and nurse practitioners ordered significantly more labs and had significantly more valid responses than attending psychiatrists. An active alert, which fired during medication order entry, was associated with a higher rate of lab ordering and valid response compared to a passive alert, which fired whenever a prescribing healthcare provider opened the chart.What is new and conclusionPrescribers may associate metabolic syndrome with schizophrenia or with use of SGAs specifically in thought disorders, even though these medications pose a risk for all indications. Higher rates of monitoring by resident physicians may have been due to spending more time with patients during the encounter and in documentation. Lastly, the active BPA was an effective tool to increase metabolic monitoring in patients taking SGAs. Continued education on the importance of regular metabolic monitoring should be implemented for all providers.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/163603/2/jcpt13236_am.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/163603/1/jcpt13236.pd