Deepali Dixit, PharmD, BCPS, BCCCP, FCCM

Heart failure (HD) is one of the most common chronic diseases associated with substantial hospital readmission, morbidity, and mortality.

 Patients hospitalized for acute HF experience a significant burden of symptoms that may lead to physical limitations and poor quality of life.

After hospital discharge, approximately 40% of these patients are readmitted within 6 months, and 1‐year mortality post discharge is substantial.

 Several randomized controlled trials have evaluated pharmacological interventions in patients hospitalized with acute HF. However, none of the therapies tested was associated with improved outcomes or readmission rates, emphasizing an urgent need to fill this gap. The sodium glucose cotransporter-2 (SGLT2) inhibitors dapagliflozin (Farxiga) and empagliflozin (Jardiance) have been shown to reduce the risk of cardiovascular death (CVD) or hospitalization for HF in patients with chronic heart failure (CHF) with a reduced left ventricular ejection fraction. Furthermore, empagliflozin has been shown to reduce the risk of CVD or hospitalization for HF in patients with CHF with a preserved left ventricular ejection fraction. The latest iteration of the heart failure guidelines include SGLT2 inhibitors for heart failure management.

 The combination of the SGLT1/2 inhibitor, sotagliflozin, has been associated with improved clinical outcomes in patients with diabetes and progressing HF. However, it was unknown whether empagliflozin provided clinical benefit in patients hospitalized for acute HF. During hospital admission for HF, therapies used to manage symptoms frequently led to considerable fluid and electrolyte shifts and hemodynamic changes. Providers often face limited available therapeutic options, and it has been uncertain whether it is safe to initiate treatment with an SGLT2 inhibitor during hospitalization.

The phase 3 EMPULSE study (NCT04157751) assessed the clinical benefit and safety of empagliflozin compared with placebo in patients hospitalized with acute HF.

 EMPULSE evaluated the effects of empagliflozin on 3 central goals of care in hospitalized patients with acute HF: reduction of heart failure event (HFE), survival benefit, and
symptom improvement.

This double-blind, international, multicenter, parallel‐group, placebo‐controlled, randomized study enrolled patients between June 2020 and February 2021. During the trial, 566 patients were screened, and
530 were randomly assigned to empagli- flozin 10 mg daily (n = 265) or placebo (n = 265). To be included in the trial, patients had to have been hospitalized with acute HF, regardless of diabetes or ejection fraction status; have systolic blood pressure of 100 mm Hg or higher; have had no symptoms of hypotension within 6 hours; have not needed an increase in intravenous (IV) diuretic dose within 6 hours; have not been on IV vasodilators, including nitrates, within 6 hours; and not have had IV inotropic drugs within 24 hours. Other criteria included N-terminal pro–B-type natriuretic peptide (NT-proBNP) of 1600 pg/mL or greater or BNP of 400 pg/mL or greater during hospitalization or within 72 hours prior to admission. The median age of participants was 71 years; 47% had diabetes, 78% were White, and 34% were women. The median time from hospital admission to being randomly assigned was 3 days, with a 90-day duration of follow-up. The primary outcome was assessed using a stratified win ratio, defined as a composite numbers of death, number of HF events, time to first HF event, and change in Kansas City Cardiomyopathy Questionnaire-Total Symptom Score (KCCQ-TSS) from the baseline to 90 days. Clinical benefit occurred at a rate of 53.9% in the empagliflozin group compared with 39.7% in the placebo (P = .005) group. The empagliflozin effect on the primary efficacy outcome was consistent across prespecified subgroups. The secondary outcome of the incidence of cardiovascular death or HFE until the end-of-trial visit was 12.8% in the empagliflozin group and 18.5% in the placebo group. There was no major difference in the proportion of patients with a KCCQ-TSS improvement of 10 points or greater at day 90 between the 2 groups. Acute renal failure was observed in 7.7% of participants taking empagliflozin vs 12.1% in the placebo group. Furthermore, the empagliflozin group had a higher reduction in NT-proBNP concentration and body weight than patients in the placebo group.

The EMPULSE findings indicate that initiation of empagliflozin in patients hospitalized for acute HF was well tolerated and showed significant clinical benefit in the 90 days after initiating treatment. In terms of safety, adverse events were higher in the placebo arm. There were no cases of ketoacidosis reported in the study.

Among patients with acute decompensated HF, empagliflozin was associated with significant clinical benefit at 90 days. The EMPULSE study enrolled participants regardless of diabetes or ejection fraction, and there was no evidence for treatment interaction based on either of these variables. The benefit of empagliflozin was independent of symptomatic impairment at baseline. Empagliflozin vs placebo also was associated with fewer deaths, improvement in quality of life, and greater reduction in body weight without any safety concerns. To date, very few interventions have shown symptom improvement and functional status in the postdischarge period in patients hospitalized with acute HF. The results of the EMPULSE trial suggest that the initiation of empagliflozin will become the standard of care in eligible patients hospitalized for acute HF.

Deepali Dixit, PharmD, BCPS, BCCCP, FCCM,

 is a clinical associate professor at the Ernest Mario School of Pharmacy Rutgers, The State University of New Jersey, and a clinical pharmacy specialist, critical care, at Robert Wood Johnson University Hospital in New Brunswick, New Jersey.

1. Tromp J, Ferreira JP, Janwanishstaporn S, et al. Heart failure around the world. 

. 2019;21(10):1187-1196. doi:10.1002/ejhf.1585

2. Tromp J, Bamadhaj S, Cleland JGF, et al. Post-discharge prognosis
of patients admitted to hospital for heart failure by world region, and national level of income and income disparity (REPORT-HF): a cohort study. 

. 2020;8(3):e411-e422. doi:10.1016/ S2214-109X(20)30004-8

3. Kosiborod MN, Angermann CE, Collins SP, et al. Effects of empagliflozin on symptoms, physical limitations and quality of life in patients hospitalized for acute heart failure - results from the EMPULSE trial. 

. Published online April 4, 2022. doi:10.1161/ CIRCULATIONAHA.122.059725

Articles

Empagliflozin also was associated with Improvement in quality of life and greater reduction in body weight.

SGLT2 Inhibitors Are Shown to Reduce HF Death and Hospitalization

Rates of problematic opioid use have been increasing since the 1990s, attributable in large part to rising life expectancy, the misuse of and surge in opioid prescriptions, and socioeconomic factors. As the opioid crisis continues, pharmacists can help alleviate and reduce the resulting morbidity and mortality.

As many as 25% of patients receiving long-term opioid therapy in a primary care setting have an addiction, and although sales of prescription opioids in the United States nearly quadrupled between 1999 and 2014, the amount of pain that Americans reported remained unchanged, according to the CDC.

Although opiates have been used for more than 8000 years, the catalyst of the current opioid crisis can be traced to the late 20th century. In the 1980s, Purdue Pharma assured health care providers that their opiate drugs carried low addiction potential and were safe for chronic pain. In addition to drug coupons for patients and incentives for Purdue Pharma’s employees, the company recruited more than 5000 physicians to speak on its behalf. Policies were enacted protecting physicians against regulatory action for prescribing opioids. As a result, providers began prescribing OxyContin liberally, and Purdue Pharma’s profits jumped more than 20-fold between 1996 and 2001. By 2012, 259 million prescriptions for opioid pain medication had been written, and by 2015, deaths by overdose had almost tripled in less than 20 years.

In 2016, the CDC created a guideline for prescribing opioids for chronic pain, which included recommendations for addressing harm and assessing risks of opioid use; determining when to continue or initiate opioids for chronic pain; and detailing opioid selection, dosage, duration, follow-up, and discontinuation.

 Pharmacists are on the front lines and can directly educate patients about proper medication efficacy and safety.

However, barriers can hinder pharmacists’ ability to fight the opioid crisis. These include inadequate or no training, a lack of confidence, and most commonly, a lack of time. In addition, patients may not fully understand the role of pharmacist and do not seek proper help.

Despite this, there have been multiple successful measures taken to address the opioid crisis. For instance, the Prescription Drug Monitoring Program (PDMP) is an electronic database that tracks controlled substance prescriptions in each state. The PDMP improves opioid prescribing, informs clinical practice, and protects at-risk patients.

PDMPs have changed prescribing behavior and decreased substance use treatment admission and the use of multiple providers by patients, according to the CDC.

A caveat to the PDMP program is that it often puts pharmacists in a difficult dual position in which they must both police patients and treat them.

Another intervention is medication-assisted treatment (MAT), which uses medications in combination with behavioral and counseling therapies to provide a patient-centered approach to the treatment of substance use disorders. Pharmacists are involved in community, inpatient, and outpatient settings to help prevent overdose mortality and provide education on the use of abuse-deterrent formulations of opioid analgesics. The MAT program uses FDA-approved medications to treat opioid dependence, such as buprenorphine, methadone, and naltrexone. The MAT program also uses naloxone (Narcan) to prevent opioid overdose by reversing the toxic effects of the overdose.

 Pharmacy schools are incorporating naloxone training into their curricula to prepare future pharmacists in the management of opioid overdose. The program has resulted in lower costs and a reduction in opioid overdoses. Pharmacists are the key to informing patients about these programs and making sure they adhere to these treatments.

In an inpatient setting, pharmacists are integral to managing patients’ pain. Clinical pharmacists review active medications, assess the need for opioids, and encourage deescalation or discontinuation of opioid treatment. Throughout the health care system, pharmacists are partnering with prescribers to ensure effective, optimal, and safe pain management for patients to prevent opioid use disorder (OUD) and overdose. The CDC Guideline for Prescribing Opioids for Chronic Pain emphasizes patient safety and encourages pharmacists and prescribers to collaborate in integrated
pain management and team-based practice models. Pharmacists and prescribers should apply the guideline and work collaboratively to optimize pain management while preventing OUD and overdoses. This will improve patient outcomes.

 Through these efforts, pharmacists closely monitor for misuse by health care professionals and patients.

Pharmacists also have been at the front line of educating patients about overdose education and naloxone prescribing, distribution, and appropriate use. When pharmacists evaluate new prescription orders, they should assess for signs of OUD or medication diversion. Signs include altered or forged prescriptions, cash payment, early or inconsistent fills, multiple prescribers, or prescriptions originating from outside the immediate geographic area. Community pharmacists should verify customer identification and the prescriber’s United States Drug Enforcement Administration registration in addition to using tools such as the PDMP.

Some pharmacies provide an FDA-approved DisposeRx at-home medication disposal packet with each prescription, which is a convenient, effective, and simple way for patients to dispose of expired or unused medications. When the DisposeRx powder and water are added to a prescription vial and shaken, a polymer gel forms that traps the drugs. It can be used with capsules, liquids, pills, and powders, and it can be thrown away in the household trash.

 This is yet another way to lessen the potential for opioid addiction or overdose.

Evidence supports a collaborative and multifaceted approach to the opioid crisis. Pharmacists, both inpatient and outpatient, can help combat the opioid crisis through monitoring the PDMP, naloxone and opioid training and dispensing, and patient education. Pharmacists are essential to helping prevent opioid misuse.

 at the Ernest Mario School of Pharmacy at Rutgers, The State University of New Jersey, in Piscataway.

, is a clinical associate professor at the Ernest Mario School of Pharmacy at Rutgers, The State University of New Jersey, and a clinical pharmacy specialist, critical care, at Robert Wood Johnson University Hospital in New Brunswick.

1. Pharmacists: on the front lines. CDC. Accessed June 14, 2022. https://www.cdc.gov/drugover- dose/pdf/pharmacists_brochure-a.pdf

2. Van Zee A. The promotion and marketing of OxyContin: commercial triumph, public health tragedy. 

. 2009;99(2):221-227. doi:10.2105/AJPH.2007.131714

3. A timeline of the opioid epidemic. Leidos. September 3, 2019. Accessed June 14, 2022. https:// www.leidos.com/insights/timeline-opioid-epidemic

4. Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain - United States, 2016. 

. 2016;65(1):1-49. doi:10.15585/mmwr.rr6501e1

5. Prescription drug monitoring programs (PDMPs). CDC. Updated May 19, 2021. Accessed April 18, 2022. https://www.cdc.gov/drugoverdose/pdmp/index.html

6. Medication-assisted treatment (MAT). Substance Abuse and Mental Health Services Administration. Updated June 10, 2022. Accessed June 14, 2022. https://www.samhsa.gov/ medication-assisted-treatment

7. DisposeRx. Accessed April 18, 2022. https://disposerx.com/page/5/product-and-program

Patient education, naloxone training, and monitoring programs make a difference.

Pharmacists Can Help Slow the Opioid Crisis

Pharmacists receive traning in general health, medication use, patient and provider education, pharmacotherapy, preventive care, and wellness. However, it was not until the early 1960s that the health care model adapted to allow pharmacists a more clinical role.

Historically, a pharmacist’s core role was dispensing medications and ensuring their safe use. In the 1960s, government health care programs began enlisting pharmacists to aid in disease management and primary care.

 By the 1970s, a core responsibility of pharmacists became drug regimen reviews, particularly in long-term care facilities—this practice has extended into all other settings in which pharmacists are employed.

 By the early 2000s, collaborative drug agreements were on the rise in government health care facilities, further expanding the scope of practice for pharmacists within direct patient care.

 The role of pharmacists and their impact on patient care is still evolving and adapting to gaps in the health care system.

Within integrated care teams, a pharmacist’s primary responsibility is to optimize patient medication therapies through continuous coordinated medication management and review.

 Pharmacists accomplish this on their own and through multidisciplinary teams by doing the following

Ensuring therapies are not lost to transitions of care

Evaluating patients and patient profiles for medication appropriateness

Identifying and discontinuing duplicate or unnecessary therapies

Identifying drug-related problems, such as allergies, dosing, drug interactions, and the potential for adverse events

Identifying potential barriers to patient adherence

Initiating or modifying medication therapy plans as patient needs change

Monitoring outcomes of medication therapy, including effectiveness and safety

Although pharmacists are qualified to take on these responsibilities, allowing them a larger role on these teams has not been easy. Studies have shown that the rate of acceptance of pharmacist recommendations by physicians and their teams can vary from 11.4% to 94.2%.

 A successful team is built through respect and trust, which depend on the professional relationships among members. Consequently, varying team dynamics and relationships cause a wide range in the acceptance rate. Teams with experience in integrating other health care professionals or that had prior relationships with pharmacists allowed for easier collaboration. Additionally, orientation and role definition are common barriers to integration.

Understanding the clinical roles and skills of pharmacists within the team fosters better relationships among health care professionals and less uncertainty about the benefits of integration. Finally, visibility and lack of resources are a major challenge to integrating pharmacists. Often, there is not dedicated space for clinical pharmacists on the floors, causing teams to sometimes forget about this resource and not consult them. This causes barriers in fostering the pharmacist-physician relationship because of lack of interaction.

However, the role of pharmacists is expanding continuously, causing a positive shift in the health care system. Although there are barriers to integrating pharmacists into primary care teams, more health care professionals and patients are recognizing the need for such integration. In a cross-sectional survey conducted in California, 90% of 69 physicians noted that integration of pharmacists in their team improved medication management, and 93% considered pharmacists’ recommendations clinically meaningful.

Furthermore, patients benefit from pharmacist-provided education, having a better understanding of the medications they are taking and being more adherent. Patients are also at reduced risk of medication-related problems because pharmacists prevent many errors prior to dispensing the medications. The results of a study involving 969 patients in Ontario, Canada, showed that when a pharmacist was integrated into a primary care team, at least 1 drug-related problem was identified and prevented in 93% of patients.

 The results of another study involving 237 patients showed that 16 pharmacists divided into different care teams found an average of 2.1 medication discrepancies and 3.6 drug-related problems per patient.

Pharmacist integration also benefits the health system. Regardless of practice setting, pharmacist-driven services have shown economic benefit: For $1 invested in pharmacist integration, more than a $4 benefit was seen.9 Evidence-based practice by pharmacists can further reduce downstream health care costs by doing the following

Providing medication reconciliation to detect and reduce drug discrepancies

Providing behavioral and educational counseling to improve medication adherence

Providing preventive care services such as immunizations

Working in collaborative practice agreements to facilitate access to care and decrease the demand of physician-provided care

Pharmacists have been advancing their practices to deliver the most qualified care in specialized areas of medicine and to provide medication information to other health care professionals. The pharmacist’s role has expanded beyond medication dispensing and management to multiple therapeutic areas and settings. These include the following:

In ambulatory settings, pharmacists play a behind-the-scenes role by reaching out to providers about alternate therapy because of cost issues, drug interactions, inappropriate prescriptions, and patient education prior to dispensing medications.

In infectious disease, pharmacists are respected members of integrated teams, with involvement in developing algorithms and antibiograms, evaluating and promoting optimal antimicrobial use, and leading antimicrobial stewardship efforts.

Oncology pharmacists work closely with nursing departments to administer anticancer medications effectively and follow up with chemotherapy management throughout a patient’s life, monitoring medication adherence and safety.

 Furthermore, oncology pharmacists in investigational drug studies are responsible for working with institutional and legal representatives to ensure that certain qualified patients have access to investigational drugs.

In critical care, physicians often rely on pharmacist recommendations regarding antibiotics. Pharmacists are heavily involved in daily rounds, evaluating and monitoring efficacy of pharmacological treatments and providing relevant information to the team.

It is worth noting that during the COVID-19 pandemic, critical care and infectious disease pharmacists have played a vital role in developing and implementing protocols.

In general practice, care team members gain drug knowledge from pharmacists, increasing safety. Although there are challenges to integrating pharmacists into primary care teams, it is ultimately beneficial, clinically and economically.

 at the Ernest Mario School of Pharmacy at Rutgers, The State University of New Jersey in Piscataway.

, is a clinical associate professor at the Ernest Mario School of Pharmacy at Rutgers, The State University
of New Jersey, and a clinical pharmacy specialist, critical care at Robert Wood Johnson University Hospital in New Brunswick, New Jersey.

1. Pearson GJ. Evolution in the practice of pharmacy-not a revolution! 

. 2007;176(9):1295-1296. doi:10.1503/cmaj.070041

2. Avalere Health LLC. Exploring pharmacists’ role in a changing healthcare environment. National Association of Chain Drug Stores. May 2014. Accessed February 8, 2022. https://www.nacds.org/pdfs/comm/2014/pharmacist-role.pdf

3. ASHP statement on the pharmacist’s role in primary care.


. 1999;56(16):1665-1667. doi:10.1093/ ajhp/56.16.1665

4. Hayhoe B, Cespedes JA, Foley K, Majeed A, Ruzangi J, Greenfield G. Impact of integrating pharmacists into primary care teams on health systems indicators: a systematic review. 

. 2019;69(687):e665-e674. doi:10.3399/bjgp19X705461

5. Byrne A, Byrne S, Dalton K. A pharmacist’s unique opportunity within a multidisciplinary team to reduce drug-related problems for older adults in an intermediate care setting. 

. 2022;18(4);2625-2633. doi:10.1016/j. sapharm.2021.05.003

6. Jorgenson D, Laubscher T, Lyons B, Palmer R. Integrating pharmacists into primary care teams: barriers and facilitators. 

. 2014;22(4):292-299. doi:10.1111/ijpp.12080

7. Kempen TGH, Kälvemark A, Sawires M, Stewart D, Gillespie U. Facilitators and barriers for performing comprehensive medication reviews and follow-up by multiprofessional teams in older hospitalised patients. 

. 2020;76(6):775-784. doi:10.1007/s00228-020-02846-8

8. Khaira M, Mathers A, Gerard NB, Dolovich L. The evolving role and impact of integrating pharmacists into primary care teams: experience from Ontario, Canada. 

. 2020;8(4):234. doi:10.3390/pharmacy8040234

9. Manolakis PG, Skelton JB. Pharmacists’ contributions to primary care in the United States collaborating to address unmet patient care needs: the emerging role for pharmacists to address the shortage of primary care providers. 

10. Chiara A. The expanding role of pharmacists: a positive shift for health care. Commonwealth Medicine. March 26, 2019. Accessed February 9, 2022. https://commed.umassmed.edu/blog/2019/03/26/ expanding-role-pharmacists-positive-shift-health-care

11. Holle LM, Segal EM, Jeffers KD. The expanding role of the oncology pharmacist. 

. 2020;8(3):130. doi:10.3390/pharmacy8030130

12. Mohiuddin AK. Pharmacists in critical care. 

. 2019;10(1):10.24926/iip.v10i1.1640. doi:10.24926/iip.v10i1.1640

Tapping their specific skill sets and training can help serve patients more effectively, although challenges exist.

Integrating Pharmacists Into Care Teams Is Crucial

will likely bring a continued focus on COVID-19’s substantial effect on prices and utilization of services.

In its annual report, health care services company Vizient predicts a 3.1% increase in total pharmaceutical spending in 2022. Oncology drugs will account for about 25% of the increase, with continued spending on pharmacotherapy related to COVID-19.

The sustained impact of COVID-19 on health care is due to the continuing emergence of disease variants coupled with vaccine hesitancy, according to Vizient.

The company also predicts that specialty pharmaceutical pricing will grow at a rate of 4.68% in 2022, driven by the likely approval of new therapies as well as price increases for adalimumab, a specialty drug used to treat autoimmune diseases.

Further, Vizient estimates that with recent endorsements from diabetes management guidelines and organizations the cost of influential diabetes agents such as glucagon-like peptide 1 and 2 and insulin, will increase by 2.63% next year. These novel diabetes drugs are gaining diverse indications beyond the management of blood glucose, such as for the prevention of cardiovascular events and other disease complications.

The report states that “when combined with the increasing prevalence of the disease, health systems are expected to see growing use of these products in their patient populations.”

The COVID-19 pandemic brought challenges that overwhelmed the health care system and required greater flexibility in cooperation and responsibilities from all essential health care providers, including pharmacists. In 2022, there will likely be continuing evolvement and expansion of the pharmacist’s role with their recognition as critical frontline workers in the fight against COVID-19. Additionally, pharmacists are extensively involved in education and research, while remaining active members of inpatient and outpatient COVID-19 recovery clinic multidisciplinary teams and vaccination efforts. Moreover, with the increased use of telehealth during the pandemic, health systems are investing more in digital innovation. Pharmacists are taking advantage of virtual postintensive care syndrome clinics, among others, to adjust medications and to counsel and educate patients. The results of a recent study show that in the beginning of 2020, 0.1% of Medicare primary care visits were conducted using telehealth, but this number increased to 43% within 3 months because of the pandemic.

 This growth is expected to continue, and some experts recommend that organizations start aligning their virtual strategies with the evolving needs.

Meanwhile, Amazon’s entry into pharmacy services may have a large impact in 2022. Consumers are so accustomed to using Amazon to order a whole slew of merchandise and it will be interesting to see how the prescription services landscape will be affected.

In 2022, organizations will continue to take a holistic approach to infusion care covering extended sites, including home infusion. Home infusion services had previously existed in health systems but some had stopped providing the service because of increased competition and payor rates. However, the pandemic led to more patients preferring to receive infusion therapy at home, leading to a heightened interest in providing these services.

Over the past decade, more than 500 health system and hospital mergers have occurred. An advantage of this partnership is the availability of large data sets that can guide health care delivery programs, prevention efforts, and wellness with wide-ranging medication management. The pursuit of medication errors prevention and quality improvement has led to a growing interest in artificial intelligence (AI) and precision medicine. An example of AI technology gaining traction in health care is machine learning, which focuses on the development and use of computer systems that can adapt and emulate without following explicit instructions. The systems use algorithms and statistical models to analyze and draw inferences from data patterns.

AI has been hailed as a transformational force in health care. In the past few years, the AI health market has experienced explosive growth, with investments worth billions of dollars, and in 2022, huge investments will likely continue to be made on the digital front. Health care is embracing AI for a range of applications, including clinical research, drug development, and robotic surgery. In addition, AI is being adopted as a practical tool to improve medication safety and patient outcomes, monitor medication adherence, reduce drug costs, replace labor-intensive and repetitive tasks that are prone to error, and streamline prior authorizations. These applications of AI will transform medication management. Thorough digestion and utilization of health care data are crucial, once the data analyses have been completed; equally important is knowing what to do based on the findings. Increasingly, real-time data assessment, models, and predictions are being used to help detect and prevent patient deterioration and manage health care crises. As data sets require the expertise and skills of data scientists, pharmacy departments will need to recruit these scientists to support predictive modeling to drive health care delivery. In 2022, AI will continue to be a priority and will have a positive and profound effect on the delivery of health care and medication management. On a similar front, genetics will continue to play a key role in personalized medication treatment to achieve the desired therapeutic effects.

Another growing trend that will continue to garner attention is the emphasis on gender inequity and sexual harassment in the pharmacy profession. In 2020, a petition titled End Gender Inequality in Clinical Pharmacy led to a response from several major pharmacy organizations. The petition advocates for gender equality, the development of policies against such behavior, and guidance and support for members of the profession who encounter gender bias, harassment, predatory conduct, or other intimidating or threatening behaviors. These organizations stand on values such as a culture that strongly supports diversity, equality, and inclusion. Major underpinning is required to promote gender equity more effectively within the profession, but this work is critical to ensuring future sustained infrastructure. Gender inequity and sexual harassment are widespread in the medical community, the pharmacy profession, and our society. All members of the pharmacy profession should have equal opportunity and support to reach their highest potential. However, major gaps in support of the diverse membership of the pharmacy profession have highlighted a lack of awareness of harassment resulting from gender and gender inequity issues. Fostering greater diversity in the workforce cultivates innovation, decreases health disparities, and improves communication, health care access, patient satisfaction, and problem solving for complex challenges.

 The potential benefits of gender equity are vast, including economic benefits, patient satisfaction, and the cultivation of diversity, innovation, and a unified profession. Women in pharmacy have started the discussion using online platforms and professional networks, but the drivers of continued change will be through organizational leadership and advocacy as well as through awareness by individual pharmacists.

In light of the pandemic’s challenges, the new year will see a continued focus on health care delivery through continued testing, vaccination, and treatment. Other important trends will include rising health care costs and an increase in digital health care. Moreover, it is hoped that progress will be made in addressing gender equity and sexual harassment in the pharmacy profession.

Deepali Dixit, PharmD, BCPS, BCCCP, FCCM, 

is a clinical associate professor at Ernest Mario School of Pharmacy at Rutgers, The State University of New Jersey in Piscataway, and a clinical pharmacy specialist in critical care at Robert Wood Johnson University Hospital in New Brunswick, New Jersey.

1. Pharmacy market outlook. Vizient. Accessed October 1, 2021. 

https:/info.vizientinc.com/pharmacy-market-outlook

2. Martin G. Top 10 emerging trends in health care for 2021: the new normal. AHA Trustee Services. Accessed October 1, 2021.https://trustees.aha.org/top-10-emerging-trends-health-care-2021-new-normal

3. Aungst TD, Franzese C, Kim Y. Digital health implications for clinical pharmacists services: a primer on the current landscape and future concerns. 

2021;4(4):514-524. doi.org/10.1002/jac5.1382

4. Institute of Medicine (US) Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine. 

The Future of Nursing: Leading Change, Advancing Health

5. Bissell BD, Johnston JP, Smith RR, et al. Gender inequity and sexual harassment in the pharmacy profession: evidence and call to action. 

 Published online July 7, 2021. doi:10.1093/ajhp/zxab275

Trends to watch include increased spending on drugs and treatments, expansion of pharmacists' role, and ongoing interest in home infusion therapy.

COVID-19 Impact Will Continue to Dominate in 2022

Post-Intensive Care Syndrome (PICS) comprises a series of ailments that patients experience upon discharge from the hospital following care for a critical illness.

These ailments may be a new occurrence or worsening of a cognitive, mental, or physical health issue. From pain to anxiety and depression to difficulty concentrating and remembering, the manifestation of PICS varies.

The overall population of critical care patients who experience PICS is unknown; however, with improved survival rates and increased ventilator users, many discharged patients experience at least 1 problem associated with PICS. These patients often have trouble returning to their pre-illness state, with some never fully recovering. Resolution of symptoms is dependent upon both the patient and the symptom, with time frames of a few weeks to several years.

PICS can appear in any patient, regardless of demographics or environment. Severity of symptoms also differs, although some risk factors have been defined. Remaining within the intensive care unit (ICU), especially while intubated and sedated, is a major risk factor for developing PICS, which can also result from dysregulated blood glucose, respiratory distress syndrome, prolonged delirium, and sepsis while in the hospital.

Unfortunately, PICS is not exclusive to the patient and can similarly be experienced by caregivers. The patient’s family can develop anxiety, depression, and post-traumatic stress disorder, and maintenance of their well-being is a crucial objective. PICS can, however, be prevented, or at least managed, through close monitoring and interventions. Caregivers, family, and the medical team, including pharmacists, can involve themselves in the patient’s critical care journey to improve the care and prognosis of PICS.

In terms of prevention, there are many factors to consider. Certain drugs used in the ICU have been found to be associated with PICS.

 Also, blood glucose levels are an important laboratory value to monitor in patients in the ICU because hyperglycemia has been found to be associated with increased morbidity and mortality.

Generally, insulin is used to manage blood glucose levels if they become elevated. The clinical guidelines recommend targeting a glucose goal of approximately 140 mg/dL to 180 mg/dL.

 If glucose levels go beyond the recommended target, that is an indication to optimize the insulin dose.

Medications for the treatment of delirium that are a concern in the development of PICS. Antipsychotics not only have weak evidence in the prevention and treatment of delirium but, when used in the ICU, they also can potentially precipitate effects of delirium or other adverse effects and increase the patient’s chances of developing PICS.

 The best way to prevent delirium is through early mobilization. Another concern is that antipsychotics and other medications initiated in the ICU are often continued erroneously during transitions of care.

In terms of comorbidities, pain and sedation are associated with an increased risk of developing PICS. When an individual is sedated for a long period of time, the likelihood of delirium increases, so light sedation using nonbenzodiazepines for the shortest amount of time is preferable. Also, in terms of pain management, nonopioid analgesics are preferred over opioid analgesics because opioids can also cause central nervous system depression and prolonged immobilization.

Monitoring these conditions closely is vital because any improvement in a patient’s status may warrant a dose reduction. Furthermore, pain should be monitored using validated pain scales, such as the Behavioral Pain Scale and the Critical-Care Pain Observation Tool. Monitoring pain helps improve patient experience and quality of life after discharge because individuals who recall pain in the ICU often develop chronic pain.

 Finally, in terms of monitoring sedation, the Richmond Agitation and Sedation Scale or another validated sedation assessment tool should be used.

Transitions of care (TOC) are an important aspect of prevention because medication errors during TOC are common.

 TOC can get complicated for a patient, especially if they are discharged with many different medications. Pharmacists can help by making sure that the medications prescribed to the patient are appropriate for the outpatient setting. Pharmacists can also screen for and discontinue any unnecessary medications to reduce the pill burden for patients. In addition, pharmacists can educate patients about the importance of medication adherence and how nonadherence can lead to the disease state worsening.

Patients who develop PICS are treated based on their symptoms. If their minds are affected, they can be started on medications and therapy. If their physical states are affected, they may initiate exercise and physical therapy. If quality of life is affected, occupational therapy is an option.

There are many avenues through which patients with PICS can heal, and PICS clinics are a promising way to start. These clinics are a developing idea in North America but are well established in Europe.

Traditionally, the clinics include multidisciplinary teams that support patients who have shown at least 1 risk factor for PICS. These teams often include nurses, occupational and physical therapists, physicians, and social workers, but pharmacists can also play a big role by reviewing medications and counseling on adherence and proper use. Through pharmacists’ efforts, therapies can be optimized and mistakes such as potential interactions or unnecessary medications that fell through the cracks during TOC can be corrected.

PICS clinics provide an invaluable opportunity to comfort and educate patients, continue care, and provide patients the opportunity to comment on and share their ICU and post-ICU experiences, empowering them in their care.

Patients requiring ICU care can experience impairments in normal bodily functions that make it difficult to perform self-care and participate in daily activities. This can have a detrimental effect on mental health and overall well-being, which can lead to a greater risk of hospitalization, institutionalization, and mortality.

It is critical to manage PICS with education, follow-up, and medication to lower the rate of these incidences and provide patients with a better quality of life once discharged from the ICU. Health care providers should participate in TOC to minimize the risks of medication error and discontinue unnecessary medications using proper guidelines and protocols. Health care providers should be aware of the risks of and treatments for PICS, not only to better serve patients, but also to help educate caregivers and family members so that they may continue to provide care outside the health care setting.

Winston Su, Olivia Wierciszewski, Kapil Rawal, 

 are PharmD candidates at the Ernest Mario School of Pharmacy at Rutgers, The State University of New Jersey in Piscataway.

is a clinical associate professor of pharmacy practice and administration at the Ernest Mario School of Pharmacy at Rutgers, The State University of New Jersey.

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Managing transitions of care is vital to discontinue use of unnecessary drugs and minimize medication errors.

Pharmacists Can Help Treat Post-Intensive Care Syndrome

Pain management in the intensive care unit (ICU) is not a one-size-fits-all discipline. There are many factors to consider, including location and type of pain, breakthrough pain despite adequate management, and patient history of opioid use. But preventing pain instead of reacting to it is key. 

It is important to keep in mind that pain management medications are not without the risks of oversedation and, ultimately, respiratory depression. Hence, it is imperative to find a balance in addressing pain by using medications that have different mechanisms of action.

The first class of medication that providers turn to is local anesthetics. Guidelines do not recommend the use of topical anesthetics in ICU patients. However, topical anesthetics can provide great advantages when other routes of administration are not plausible. Lidocaine is a local anesthetic that binds reversibly to sodium channels, blocking nerve depolarization by locking nerves in the open state.

 One study evaluated pretreatment with lidocaine 5% patches in acute potthoracotomy population pain. Results found that lidocaine was effective in reducing pain intensity and total morphine consumption. Therefore, lidocaine 5% patches could be considered as an adjunct treatment to intravenous (IV) morphine to control postthoracotomy pain.

 Nevertheless, the results of another study assessing the efficacy of topical lidocaine 5% patches in ICU patients in poststernotomy or postthoracotomy pain concluded that lidocaine did not reduce acute pain.

Because of their low risk of systemic effects, minimal drug interactions, and safety profiles, lidocaine patches are considered a suitable treatment for the elderly population. However, variable skin properties in individuals may influence absorption and distribution. Additionally, many studies of topical medications lack quality; thus, further studies are needed to analyze effectiveness and long-term effects.

The guidelines also suggest using low-dose ketamine for pain relief in post-operative adults in the ICU.

-aspartate and glutamate receptor antagonist. It is recommended as an adjunct to opioid therapy to reduce opioid consumption in ICU patients with postsurgical pain. Common adverse effects (AEs) include confusion, diplopia, drowsiness, dysphoria, and, in some rare cases, hallucinations.

Although opioids remain the mainstay of therapy in the ICU, the guidelines also recognize the negative effects that opioids pose and encourage the use of multi-modal therapies whenever possible to decrease opioid use.

 Two other classes of medications used in the ICU are nonsteroidal anti-inflammatory drugs (NSAIDs), and acetaminophen, an analgesic, and antipyretic medication. NSAIDs work by inhibiting prostaglandin synthesis through COX-1 and COX-2 inhibition.

 Patients must have stable renal functions and not be on concomitant nephrotoxic medications while receiving NSAIDs. These drugs should also be avoided in patients with gastric ulcers, active gastrointestinal (GI) bleeds, or a history of GI bleeds, and congestive heart failure.

 Additionally, in patients with severe cirrhosis or liver impairment, alternatives should be considered.

Acetaminophen is the preferred initial agent of choice for ICU patients.

 According to the guidelines, IV, oral, or rectal acetaminophen should be used for pain control and to decrease opioid use in the critically ill population.

 Acetaminophen has proved to have comparable effects to opioids and demonstrated an opioid-sparing effect in multiple investigations. In 1 study looking at moderate to severe pain after orthopedic surgery, results showed  that IV acetaminophen at a dose of 1 g, administered over 24 hours, reduced opioid need, and was well tolerated.

 The results of another study showed that the addition of acetaminophen to meperidine provided adequate pain control in patients and reduced their opioid need.

 Results from another trial demonstrated adequate pain control and opioid-sparing effects through the combined use of acetaminophen and tramadol in patients who have cardiac surgery.

Similar opioid-sparing effects can be seen with NSAIDs, such as ibuprofen and ketorolac. Study results showed that using 800 mg of IV ibuprofen every 6 hours in patients who had postabdominal pain effectively controlled their pain and reduced their opioid requirements.

 The results of one controlled, randomized trial comparing IV morphine 4 mg with IV ketorolac 4 mg showed that pain scores were similar after chest tube removal. These results indicated that NSAIDs could be used as an alternative to opioid therapy in the critically ill population for certain procedures.

 When using ketorolac, it is imperative to maintain therapy for no more than 5 days, as prolonged therapy can increase the risk of AEs, particularly GI bleeding.

 Patients should be evaluated to determine whether they are good candidates for either acetaminophen of NSAID therapy alone or in combination with opioids to decrease AEs and opioid burden and help prevent pain.

Finding the right medication or drug combination for individual patients is critical.