Current issues and recommendations to manage prescription drug benefits for public health programs.

Higher scrutiny is befalling public payors regarding drug costs and patient access to medications. These issues exist in a complex contractual environment where minimal oversight of pharmacy claim adjudication and reimbursement practices can occur. The complexity of prescription benefits, and the lack of defined expectations or accountability in the system contribute to a sense of frustration by the public.

Three ways to advocate for the economic value of the pharmacist in health care.

Numerous studies have demonstrated positive therapeutic and economic outcomes associated with pharmacist-provided care. However, public policy on provider status with subsequent payment for non-dispensing services has been slow to reflect an expanded pharmacist role. It is important for the public to understand the value of a pharmacist outside of the drug distribution system.

Report of the 2018-2019 Strategic Engagement Standing Committee.

Strategic engagement is critical to the success of colleges and schools of pharmacy in expanding pharmacy and public health practice, meeting programmatic needs, and fulfilling institutional missions. The AACP 2019-2020 Strategic Engagement Committee was charged with exploring faculty leadership and development as they relate to strategic engagement, considering challenges and barriers to faculty participation and identifying successes in faculty engagement and opportunities for professional development. The committee reviewed literature and examples regarding strategic engagement across academic pharmacy, with strategic engagement understood as being part of the service mission of academic institutions.

Developing a Business Plan for Critical Care Pharmacy Services.

Critical care medicine has grown from a small group of physicians participating in patient care rounds in surgical and medical intensive care units (ICUs) to a highly technical, interdisciplinary team. Pharmacy's growth in the area of critical care is as exponential. Today's ICU requires a comprehensive pharmaceutical service that includes both operational and clinical services to meet patient medication needs.

Pharmacokinetic study in pigs and in vitro metabolic characterization in pig- and human-liver microsomes reveal marked differences in disposition and metabolism of tiletamine and zolazepam (Telazol).

1. An equal-dose combination of tiletamine and zolazepam (Telazol®) is used as a veterinary anesthetic. There also have been reports of human abuse of Telazol®.

In vitro characterization of oritavancin clearance from human blood by low-flux, high-flux, and continuous renal replacement therapy dialyzers.

Background: Oritavancin is an investigational lipoglycopeptide antibiotic under clinical development for the treatment of gram-positive bacterial infections. The impact of hemodialysis on plasma concentrations of oritavancin is unknown and may be important in making dosage adjustments in such patients. The present study sought to determine the clearance of oritavancin from human blood by various commercially available dialyzers in an in vitro hemodialysis model.

Cooperation in pharmacy education in Canada and the United States.

Although the education of student pharmacists and the practice of pharmacy in Canada have many similarities with that in the United States, there also are differences. The planning of curricula in pharmacy education is of particular importance to the advancement of pharmacy in Canada because of significant changes in the scope of practice in several provinces, and in how community pharmacy is reimbursed for the services it can, or should, provide. Greater dialog between Canadian and American pharmacists has the potential not only to impact practice on both sides of the border but also to improve collaborations among Canadian and American pharmacy educators.

Visual compatibility of oritavancin diphosphate with selected coadministered drugs during simulated Y-site administration.

Purpose: The visual compatibility of the new intravenous antibiotic oritavancin diphosphate with various drugs commonly administered to patients in acute care settings was studied.

Methods: Clinically used concentrations of 37 drugs, including antibiotics, sedatives, analgesics, and cardiovascular agents, were evaluated in 1:1 mixtures with oritavancin concentrations of 0.8, 1.

Drug metabolism in hemorrhagic shock: pharmacokinetics of selective markers of cytochrome-P450 2C9, 2D6, and 3A4 enzyme activities in a porcine model.

Background: Cytochrome-P450 enzymes metabolize most administered drugs. A variety of clinical conditions affect the CYP system. However, the effect of hemorrhagic shock on CYP-mediated drug metabolism in clinical setting or in clinically applicable in-vivo models is largely unknown.

Inadequate antibiotic therapy in solid organ transplant recipients is associated with a higher mortality rate.

Background: Inadequate antibiotic therapy and failure to administer antibiotics in a timely fashion have been associated with substantial mortality rates in patients in the intensive care unit (ICU). We analyzed the infection pattern in solid organ transplant recipients as well as the impact of antibiotic resistance and inadequate antibiotic treatment on mortality rates and morbidity outcomes.

Methods: Charts of adult solid organ transplant recipients in 2006 from a single institution were reviewed.

Forging a critical alliance: Addressing the research needs of the United States critical illness and injury community.

Objective: Discuss the research needs of the critical illness and injury communities in the United States.

Data Sources: Workshop session held during the 5 National Institutes of Health Symposium on the Functional Genomics of Critical Illness and Injury (November 15, 2007).

Study Selection: The current clinical research infrastructure misses opportunities for synergy and does not address many important needs.

Protein C in critical illness.

Purpose: The role of protein C in critical illness is assessed.

Summary: Conversion of protein C to activated protein C (APC) requires thrombin and thrombomodulin. When thrombin is not bound to thrombomodulin, it can convert fibrinogen to fibrin, factor V to factor Va, and factor VIII to factor VIIIa but will not convert protein C to APC.

Multicenter implementation of a consensus-developed, evidence-based, spontaneous breathing trial protocol.

Objective: Evidence-based practice recommendations abound, but implementation is often unstructured and poorly audited. We assessed the ability of a peer network to implement an evidence-based best practice protocol and to measure patient outcomes.

Design: Consensus definition of spontaneous breathing trial followed by implementation in eight academic medical centers.

The science of implementation: changing the practice of critical care.

Purpose Of Review: Few would disagree that evidence from clinical research should be brought to the bedside in an efficient and equitable manner. Unfortunately, this common agreement does not result in practice change at the bedside where delayed and variable implementation is common. Recognition of this gap has resulted in a new discipline called implementation science that seeks to understand the reasons for slow adoption of clinical therapeutics and to discover effective strategies that accelerate practice change.

Simultaneous analysis of cytochrome P450 probes-dextromethorphan, flurbiprofen and midazolam and their major metabolites by HPLC-mass-spectrometry/fluorescence after single-step extraction from plasma.

Cytochrome P450 enzymes catalyze oxidative metabolism of most pharmaceutical compounds. Consequently dextromethorphan, flurbiprofen, midazolam and other compounds are commonly used as probe substrates to evaluate cytochrome P450 function in humans. A "cocktail" approach employing simultaneous administration of two or more of the probe substrates has been used by various investigators in recent years.

Update on the management of cardiogenic shock.

Purpose Of Review: Cardiogenic shock is a life-threatening emergency that occurs frequently with acute coronary syndromes. If rapid myocardial reperfusion following acute myocardial infarction is not obtained, either with thrombolytics or by revascularization, cardiogenic shock frequently develops and the mortality rate is high. This review summarizes recent advances in the pathophysiology, incidence and treatment of cardiogenic shock.

Determination of constituents of Telazol--tiletamine and zolazepam by a gas chromatography/mass spectrometry-based method.

Tiletamine and zolazepam injection (Telazol) is used in veterinary surgical practice to induce short-term anesthesia and also to immobilize wild animals. The present work describes a sensitive method to measure tiletamine and zolazepam concentrations in plasma by means of GC/EI-MS on a 5% phenyl/95% methylpolysiloxane column. A simple liquid extraction procedure with ethyl acetate was used to isolate the two compounds and the same were separated and analyzed by GC/MS without derivatization.

Drug-associated disease: cytochrome P450 interactions.

Critically ill patients generally are older, frequently have organ failure, and commonly receive multiple medications, all of which make them susceptible to adverse effects of drugs. Drug interactions are a common adverse effect, and many are predictable based on understanding the mechanisms that underlie drug interactions. This article identifies commonly used medications in critically ill patients and the associated drug interactions that may occur with emphasis on the cytochrome P450 enzyme system.

Physical and chemical compatibility of drotrecogin alfa (activated) with 34 drugs during simulated Y-site administration.

Purpose: The physical and chemical compatibility of drotrecogin alfa (activated) (recombinant human activated protein C) during simulated Y-site administration with drugs commonly used to treat patients with severe sepsis was determined.

Methods: Thirty-four drugs were investigated for visual compatibility with drotrecogin alfa, and included cardiovascular agents, conscious sedative agents, antibiotics, blood products, and other supportive care drugs. The physical and chemical compatibility of drotrecogin alfa with these drugs was determined using a well-established experimental model to simulate Y-site administration.

Appraisal of four novel approaches to the prevention and treatment of sepsis.

Purpose: Four novel approaches to the management of sepsis are discussed.

Summary: Drotrecogin alfa (activated) has FDA-approved labeling for use in the treatment of severe sepsis. Risk of bleeding and identification of the most suitable patients have been the major issues related to use of this drug.

Current issues regarding the use of drotrecogin alfa (activated).

The key issues clinicians are facing regarding drotrecogin alfa (activated) include questions concerning the pathophysiology and appropriate patient selection for administration of this drug. In the Recombinant Human Activated Protein C Worldwide Evaluation in Severe Sepsis (PROWESS) trial, the efficacy of drotrecogin alfa (activated) was demonstrated in patients with severe sepsis. Because of this trial's strict inclusion and exclusion criteria, however, the applicability of the study criteria to different types of patients raises important issues.

Recombinant human activated protein C in severe sepsis.

The role of activated protein C (APC) in coagulation, inflammation, and fibrinolysis and the pharmacology, pharmacokinetics, and trials of recombinant human activated protein C (rhAPC), or drotrecogin alfa (activated), in sepsis are described. Protein C, a naturally occurring vitamin K-dependent serine protease in the blood, remains inactive until exposed to the thrombin-thrombomodulin complex. This change between the inactive and active forms occurs constantly in humans and serves to balance the coagulation cascade.