Anticoagulant Drug-Drug Interactions with Cannabinoids: A Systematic Review

Introduction This systematic review evaluates the extent to which the effect of anticoagulants may be altered in the presence of cannabinoids. Methods The following databases were searched: EMBASE, PubMed, Web of Science, Scopus, PscycINFO, and CINAHL from database inception through May 2023. Search terms included cannabis AND anticoagulant AND drug interactions, and related key words. The major outcome was hemorrhage or thrombosis and if available, the relative change in quantitative intensity of anticoagulation after cannabinoid exposure. Results The search generated 959 citations. After removal of 440 duplicates, 519 citations were screened. Overall, with the exception of warfarin, evidence supporting an interaction between cannabinoids and anticoagulants is non-existent. Seven case reports evaluating an interaction with warfarin were reported. Cannabis doses involved were either extremely high (e.g., \u3e260 mg/day of delta-9-tetrahydrocannabidiol [THC] or \u3e600 mg/day of cannabidiol [CBD]) or were not known. Hemorrhage was identified in 14.2% (1/7) of reports and thrombosis in 0%. Quantitative anticoagulation levels were increased in patients on warfarin (elevated International Normalized Ratio [INR]) in 6 of 7 cases. A maximum INR change was available in 5 of 7 reports, ranging from +0.4 to +9.61. One report found no change in INR after 4 days of medical cannabis exposure. Another report outlined two separate episodes of INR elevation associated with bleeding requiring hospitalization and reversal after marijuana smoking. Four cases involved reduction in weekly warfarin dose ranging from 22% to 31%. The Drug Information Probability Score was calculated in 6 cases, with a score of probable for 5 cases and possible for one. Conclusions Very low-quality data support a potential drug-drug interaction with warfarin and both THC and CBD. Clinician recognition of this potential interaction is important. Available evidence supports the need to conduct a drug interaction study between cannabinoids and warfarin to clarify the existence of an interaction

INSTRUCTIONAL DESIGN AND ASSESSMENT An Innovative Elective Course in Anticoagulation Management

Objective. To develop and implement an elective pharmacy course in anticoagulation management and assess student learning. Design. Students participated in active-learning activities including evaluating a patient receiving outpatient or inpatient anticoagulation therapy, participating in a team project and presentation, and completing a ''living with anticoagulation'' assignment that included modeling both the health care provider's and the patient's role. Assessment. A precourse and postcourse standardized examination on anticoagulation along with a short answer midterm and final examination were administered. Performance between precourse and postcourse examination improved by approximately 25%, and 90% of students scored $ 90% on the final examination. Reflective narratives provided support that students found the ''living with anticoagulation'' assignment a valuable learning experience which developed empathy towards patients. Conclusion. An elective course in anticoagulation management that included multiple active-learning assignments was successful in increasing both students' knowledge and empathy

Ambulatory Care Practice in the COVID-19 Era: Redesigning Clinical Services and Experiential Learning

The Coronavirus Disease (COVID‐19) has created a variety of challenges for healthcare professionals, including ambulatory care clinical pharmacists. High‐quality remote and minimal‐contact care has become a necessity. Ambulatory care clinical pharmacists around the nation have adjusted their practice. In many cases, this included implementation of telehealth programs for comprehensive medication management. The redesign of ambulatory care Advanced Pharmacy Practice Experiences (APPE) also required quick adaptation. In this paper, we describe the clinical practice and experiential education challenges encountered by an ambulatory care clinical pharmacist workgroup in a COVID‐19 “hotspot,” with an emphasis on solutions and guidance. We discuss how to adapt ambulatory care clinical pharmacy practices including methods of minimal‐contact care, reimbursement opportunities, tracking outcomes, and restructuring ambulatory care APPE. As ambulatory care clinical pharmacists continue to expand the services they provide in response to COVID‐19, we also describe opportunities to promote pharmacists as providers during times of pandemic and into the future

Preventive health therapy and behavior outcomes from a brown bag medication review for older adults

BACKGROUND: Morbidity and mortality associated with preventable diseases can be reduced with the use of preventive health services. We evaluated the uptake and retention of preventive health behaviors and management of accidental medication poisonings in older adults after a health prevention educational component was combined with a brown bag medication review. METHODS: This study used a cohort design and was conducted in six urban senior centers and three independent senior living communities in Detroit, Michigan. Participants included 85 older adults (\u3e60 years old) taking five or more medications with 63 participants returning follow up materials. Pharmacy personnel conducted brown bag medication reviews that were combined with a preventive health education component. Information was collected on medications, vaccinations, supplement use, and accidental medication poisoning management. Participants were given written recommendations on prescription medications and preventive health therapies to improve health and medication use. An investigator developed program satisfaction survey was administered immediately after the review. An investigator-developed follow-up preventive health implementation survey was conducted at least 3 months later to assess recommendation implementation. RESULTS: Participants\u27 mean age was 75.9 ± 8.5 years. Fifty-six older adults had 124 recommendations in preventive health in total (1-5/participant). Eleven participants had no recommendations. Sixty-three participants (74%) returned follow-up preventive health surveys. Twenty-three percent of recommendations were already implemented with 34% planned to be done in the future. Poisoning management knowledge increased for 13 participants, reporting they would call the poison control center. The program was well received, with participants reporting high satisfaction scores (4.8 ± 0.7 out of 5). CONCLUSIONS: Brown bag medication reviews can be an effective method to promote the uptake of preventive health behaviors among older adults, but additional accidental medication poisoning management education is still needed