Marilyn Bulloch, PharmD, BCPS, FCCM

The last week of April is World Immunization Week, which is a week that acts to highlight the role of immunizations in the prevention of illness and the reduction of disease transmission. Each year, vaccines prevent 2 to 3 million deaths related to diseases such as diphtheria, tetanus, pertussis, influenza, and measles.

 The Centers for Disease Control and Prevention (CDC) estimates that the number of influenza-related hospitalizations in the United States have ranged from 140,000 to 710,000 since 2010, but that the influenza-related deaths have only ranged from 12,000 to 60,000.

The accessibility of pharmacists contributes greatly to the immunization of the community. Approximately 90% of people in America live within 5 miles of a community pharmacy, which has increased the ability for many Americans to receive same-day vaccines.

Pharmacists began immunizing in 1996 when the American Pharmacists Association (APhA) introduced a training certificate program for pharmacists; by 2004, around 15,000 pharmacists and pharmacy students had been formally trained to immunize.

 As of 2020, more than 360,000 trained pharmacists across the United States were authorized to administer vaccines, and today, every state allows pharmacists to administer immunizations.

The role of the pharmacist in vaccinating the US population against COVID-19 during the COVID-19 pandemic is a recent example of pharmacists’ critical contribution to the immunization of communities. For many during the pandemic, pharmacists were the only direct health care providers available in 2020 and 2021 due to physician visit cancellations, reduced hours, and temporary closings. During this time, pharmacies remained open, and some even provided extended hours to high-risk individuals. Once the COVID-19 vaccines were available, pharmacists quickly adapted. As of April 6, more than 239.1 million COVID-19 vaccines had been administered and reported by community pharmacies.

“One of the greatest privileges and responsibilities we have as a profession in public health is vaccination. While the COVID-19 pandemic highlighted the incredible contribution of pharmacists to vaccinations, we have been performing these valuable patient care services for a long time,” said Christopher Bland, PharmD, BCPS, FIDSA, FCCP, a clinical professor at the University of Georgia College of Pharmacy with over 20 years of clinical experience. “I hope these important contributions lead to even more widespread adoption of pharmacist clinical services, including rapid diagnostic testing of infectious diseases and treatment when appropriate.”

A review article in 2016 looked at 36 studies assessing the role of pharmacists as educators, facilitators, and/or administrators of vaccines. All studies reviewed found an increase in vaccine coverage when pharmacists were involved in the immunization process.

 Another study looked at the cost-effectiveness of pharmacy-based immunization services (PBIS). It was concluded that PBIS are a cost-effective way to increase adult vaccination rates, particularly in their ability to engage under-vaccinated populations that have been difficult to reach through traditional methods.

It is important to recognize the impact pharmacists have on major health issues such as immunizations. By being readily accessible, pharmacists can continue to positively contribute to vaccination rates. In some areas, the community pharmacist may be the primary vaccination resource.

The goal of World Immunization Week is to support the ongoing protection of people and communities from vaccine-preventable diseases.

 The 2022 theme of World Immunization Week is “Long life for all,” which acts as a reminder that vaccines have played a large role in the increased life expectancy, decreased childhood mortality, and decreased post-infection complications (which could be lifelong) from previous generations.

Each time a pharmacist immunizes a patient against one of the 27 dangerous infections for which a safe and effective vaccine exists, the profession continues to strive to support and protect our communities against diseases that wreaked havoc on generations of people. However, society is longer affected by these diseases because of the efficacy and safety of vaccines that helped to eliminate them. This World Immunization Week, take time to let your patients know the role you play in immunity and health.

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Articles

Each time a pharmacist immunizes a patient against one of the 27 infections for which a safe and effective vaccine exists, the profession continues to protect communities against diseases that wreaked havoc on generations. 

Recognizing the Important Work of Pharmacists as Immunizers During World Immunization Week

February is recognized as American Heart Month, as patients are encouraged to follow the 28 Days Towards a Healthy Heart calendar to spread awareness and reduce the risk of cardiovascular disease.

 In the middle of the month, a week is dedicated to heart failure awareness, which affects nearly 6.2 million American adults, 5 million of whom are living with congestive heart failure (CHF).

CHF results in more hospitalizations than all forms of cancer combined, and it is the most common diagnosis of hospitalized patients 65 years of age or older.

 Although February is the shortest month of the year, heart failure is not an acute event and accounts for complex polypharmacy that can lead to a myriad of negative patient outcomes through inappropriate prescriptions, poor adherence, adverse effects (AEs), and drug-drug interactions.

Among those who are hospitalized with CHF, 17%-27% are readmitted within 30 days, with 50% being readmitted within 6 months.

 These high readmission rates and complicated medication regimens provide an opportunity for pharmacists to create an impactful change for this patient population.

Medication adherence is critical to prevent detrimental exacerbations and control debilitating heart failure symptoms for these patients. However, the pill burden associated with CHF is coupled with comorbid conditions such as depression, anxiety, and executive function impairment, which can further decrease medication adherence.

Pharmacists can collaborate with patients to improve medication adherence, decrease polypharmacy AEs, and improve quality of life. A meta-analysis of 6665 studies from Europe, Asia, and North America found that patient-centered medication adherence interventions (medication education and disease education) by pharmacists resulted in improved adherence behavior outcome effects (ES= 0.63, p=0.049) when compared to the groups based on prescriber-focused health care behavior (ES= -0.12, p < 0.001).

Moreover, a small, randomized, control trial studying pharmacist-led medication assessments (medication-condition matching chart via START criteria, medication underuse, and need for deprescribing via STOPP criteria) showed that 100% of participants reported a reduction in AEs likely attributed to polypharmacy and potentially inappropriate medication use.

 These decreased AEs and increased patient education can improve patients’ quality of life and further strengthen the practice of patient-centered care.

In addition to negative health outcomes, poorly controlled CHF accounts for nearly $30.7 billion in national health care costs.

 Pharmacists adopting the role of managing unnecessary pill burden through proper medication reconciliation and successful transitions of care has proven to reduce these exponential health care costs.

A coordinated interdisciplinary team of pharmacists partnering with ambulatory physicians for medication therapy management programs of pill burden disease states, such as CHF, resulted in decreased health care costs (63.2% yearly inpatient savings) with a benefit-to-cost ratio of 3.51:1 for the 16-month implementation period.

 The cost savings were a result of decreased total patient medical expenses due to lessening the pill burden by deprescribing inappropriate agents along with increased patient education resulting in hospitalization preventions from improved medication adherence.

Approximately 30%-50% of CHF hospital admissions are preventable if patients can afford to purchase and remember their monthly medications.10 Treatment guidelines for CHF can require 5-10 medications upon hospital discharge with an average monthly outpatient medication cost of $340 for patients who only have CHF; this number increases significantly to $730 per month for patients with CHF who also have chronic obstructive pulmonary disease and diabetes mellitus.

The increased medication costs are parallel to the increased frequency of daily medications needed for CHF management (average 10.1 doses per day).

 These numbers can leave patients feeling overwhelmed and alone.

Pharmacists can aid by finding manufacturer coupons and following up with uncontrolled patients. Numerous studies exploring implementation of pharmacy-led transition of care programs showed that receipt of a follow-up phone call from the care-transition pharmacist within 72 hours after discharge led to a significantly lower overall 30-day acute care services use rate of 22% (vs 42% for those who did not receive a phone call; P = 0.01) and a 48% lower likelihood of requirement for acute-care services within 30 days of discharge (risk ratio = 0.52; 95% confidence interval [CI] 0.33–0.82).

The complexity of CHF management provides many opportunities for pharmacists to adopt impactful roles in these patients’ lives through medication therapy management, patient education, interdisciplinary collaboration, and coordinated transition of care. By and large, American Heart Month is another example of the essential and valuable position that pharmacists hold in improving health care outcomes and optimizing patient-centered care.

American Heart Month [Internet]. National Heart Lung and Blood Institute. U.S. Department of Health and Human Services; 2022 [cited 2022Feb1]. Available from: https://www.nhlbi.nih.gov/education/american-heart-month

Heart Failure Awareness Week 2022 [Internet]. Heart Failure Society of America. [cited 2022Feb1]. Available from: 

https://hfsa.org/heart-failure-awareness-week-2022

Heart Failure [Internet]. Centers for Disease Control and Prevention; 2020 [cited 2022Feb1]. Available from: https://www.cdc.gov/heartdisease/heart_failure.htm

Heart Failure Statistics [Internet]. www.emoryhealthcare.org. Emory Healthcare; [cited 2022Feb1]. Available from: 

https://www.emoryhealthcare.org/heart-vascular/heart-failure.html

Mastromarino V, Casenghi M, Testa M, Gabriele E, Coluccia R, Rubattu S, Volpe M. Polypharmacy in heart failure patients. Curr Heart Fail Rep. 2014 Jun;11(2):212-9. doi: 10.1007/s11897-014-0186-8. PMID: 24493574.

Toback M, Clark N. Strategies to improve self-management in heart failure patients. Contemp Nurse. 2017 Feb;53(1):105-120. doi: 10.1080/10376178.2017.1290537. Epub 2017 Feb 19. PMID: 28151071.

Ruppar TM, Delgado JM, Temple J. Medication adherence interventions for heart failure patients: A meta-analysis. Eur J Cardiovasc Nurs. 2015 Oct;14(5):395-404. doi: 10.1177/1474515115571213. Epub 2015 Feb 10. PMID: 25669661.

Whitman A, DeGregory K, Morris A, Mohile S, Ramsdale E. Pharmacist-led medication assessment and deprescribing intervention for older adults with cancer and polypharmacy: a pilot study. Support Care Cancer. 2018 Dec;26(12):4105-4113. doi: 10.1007/s00520-018-4281-3. Epub 2018 Jun 4. PMID: 29869294; PMCID: PMC6204077.

Lin HW, Lin CH, Chang CK, Chou CY, Yu IW, Lin CC, Li TC, Li CI, Hsieh YW. Economic outcomes of pharmacist-physician medication therapy management for polypharmacy elderly: A prospective, randomized, controlled trial. J Formos Med Assoc. 2018 Mar;117(3):235-243. doi: 10.1016/j.jfma.2017.04.017. Epub 2017 May 23. PMID: 28549592.

Hussey LC, Hardin S, Blanchette C. Outpatient costs of medications for patients with chronic heart failure. Am J Crit Care. 2002 Sep;11(5):474-8. PMID: 12233973.

Page RL, O’Bryant CL, Cheng D, Dow TJ, Ky B, Stein CM, et al. Drugs that may cause or exacerbate heart failure. Circulation. 2016;134(6):32–69.

Anderson SL, Marrs JC. A Review of the Role of the Pharmacist in Heart Failure Transition of Care. Adv Ther. 2018 Mar;35(3):311-323. doi: 10.1007/s12325-018-0671-7. Epub 2018 Feb 27. PMID: 29488151; PMCID: PMC5859692

American Heart Month is another example of the essential and valuable position that pharmacists hold in improving health care outcomes and optimizing patient-centered care.

American Heart Month: A Pharmacist’s Role in Polypharmacy Management of Congestive Heart Failure Patients

December is celebrated around the world as a month full of holiday laughter and cultural traditions; however, December is also nationally recognized as Drunk and Drugged Driving Prevention month in the United States. In 2018, the National Highway Traffic Safety Administration reported 839 fatal alcohol-related vehicular accidents in December. Specifically, the multiple crashes on December 24 and December 31 increased impaired driving accidents to account for approximately 50% of all traffic fatalities that year.

Between the months of March and July in 2020, nearly two-thirds of drivers involved in vehicular wrecks tested positive for at least 1 active drug including alcohol, marijuana, and opioids.

 All 50 states have laws claiming impaired driving to be illegal; yet, many people do not understand that driving under the influence (DUI) not only includes intoxication from alcohol or illicit substance use but also impairment from legal prescription medications.

 As medication experts, pharmacists can serve a life-saving role as educators of the public and their patients on the facts and hazards of driving while impaired under legal prescription medications.

The primary concerning medications are drugs that cause excessive drowsiness such as opioids, benzodiazepines, and even some anticonvulsants and antipsychotics.

 Excessive drowsiness impairs cognitive function by decreasing alertness, impairing judgment, and slowing reaction time—all of which negatively impact a person’s driving capability.

While there is limited data concerning impaired driving with legal prescriptions, a meta-analysis of 15 studies involving prescription opioid use while driving reported an increased odds ratios of 2.29 (95% CI: 1.51, 3.48) for crash risk and 1.47 (95% CI: 1.01, 2.13) for crash culpability.

 Additionally, 2 other meta analyses regarding driving while influenced under benzodiazepines concluded an associated 60% (for case-control studies: pooled odds ratio [OR] 1.59; 95% CI 1.10, 2.31) to 80% (for cohort studies: pooled incidence rate ratio 1.81; 95% CI 1.35, 2.43) increase in the risk of traffic accidents and a 40% (pooled OR 1.41; 95% CI 1.03, 1.94) increase in 'accident responsibility.'

Furthermore, the odds ratio in the accident risk pool increased by 7.7-fold with co-ingestion of benzodiazepines and alcohol (pooled OR 7.69; 95% CI 4.33, 13.65).6 These increased hazard risks directly impact pharmacists because 27 out of 100 annual physician visits result in a benzodiazepine prescription, with one-third of these visits involving an overlapping opioid prescription, according to the National Health Statistics Report.

 Thus, pharmacists should be aware of strategies that can easily be adopted to prevent public harm through DUIs that are due to intoxication from legal prescription medications.

One strategy emphasizes the importance of acknowledging a patient’s health literacy and providing comprehendible patient education. Pharmacists can help decrease DUI events through proper patient counseling at every CNS depressant prescription pick-up.

‘May cause drowsiness’ prescription labels can help warn patients; however, many patients do not know how to properly comprehend prescription labels. Specifically, studies have shown that the use of certain terminology in particular can negatively impact a patient’s ability to understand prescription labels.

 For example, the safety label that warns patients to not drive or operate heavy machinery while taking opioids does not specify that automobiles are considered heavy machinery. If a pharmacist does not explain this terminology to the patient, then the patient may operate a vehicle while under the influence of narcotics simply because they were not counseled effectively.

Another strategy that pharmacists can employ to prevent DUIs is to be mindful of older patients who are prescribed medications on the Beers Criteria List—especially those with anticholinergic or sedative effects. A meta-analysis found an increase in vehicular accident risk among 65 years and older patients who were taking tricyclic antidepressants when compared to younger patients.

While some medications on the Beers List are very common and safe to use, pharmacists must still be proactive and cautious to prevent impaired driving in every patient population. Additionally, despite many DUI cases occurring in the month of December, everyday pharmacists should serve the life-saving, preemptive role of comprehensive patient counseling and thorough medication assessment to prevent DUIs, decrease vehicular fatalities, and help patients arrive safely to their destinations.

This December, as people are coming together once more to celebrate the holiday season and the end of another year, pharmacist should remain vigilant for opportunities to intervene and reduce impaired driving. While this is an area many people may not assume is related to pharmacy, the fact is that many of the medications our patients take on a day-to-day basis can be implicated. Our involvement and awareness will not only benefit our individual patients, but our entire community. By helping raise awareness regarding what could contribute to DUIs and impaired driving, we can help reduce the tragic results that a DUI can cause.

Media MADD. December is National Impaired Driving Prevention Month [Internet]. MADD. 2020 [cited 2021Nov3]. Available from: https://www.madd.org/december-is-national-impaired-driving-prevention-month

United States Department of Transportation National Highway Traffic Safety Administration, Office of Behavioral Safety Research. Update to special reports on traffic safety during the COVID-19 public health emergency: Fourth quarter data [traffic safety facts] [Internet]. National Transportation Library. United States. National Highway Traffic Safety Administration. Office of Behavioral Safety Research; 2021 [cited 2021Nov3]. Available from: https://rosap.ntl.bts.gov/view/dot/56125

National Center for Injury Prevention and Control. Impaired driving [Internet]. Centers for Disease Control and Prevention. Centers for Disease Control and Prevention; 2020 [cited 2021Nov3]. Available from: https://www.cdc.gov/transportationsafety/impaired_driving/index.html#:~:text=Impaired%20Driving%20%7C%20Motor%20Vehicle%20Safety%20%7C%20CDC%20Injury%20Center

Sigona N, Williams KG. Driving under the influence, public policy, and pharmacy practice. J Pharm Pract. 2015 Feb;28(1):119-23. doi: 10.1177/0897190014549839. Epub 2014 Oct 13. PMID: 25312259.

Chihuri S, Li G. Use of prescription opioids and motor vehicle crashes: A meta analysis. Accid Anal Prev. 2017 Dec;109:123-131. doi: 10.1016/j.aap.2017.10.004. Epub 2017 Oct 20. PMID: 29059534.

Dassanayake T, Michie P, Carter G, Jones A. Effects of benzodiazepines, antidepressants and opioids on driving: a systematic review and meta-analysis of epidemiological and experimental evidence. Drug Saf. 2011 Feb 1;34(2):125-56. doi: 10.2165/11539050-000000000-00000. PMID: 21247221.

Santo L, Rui P, Ashman J. Physician Office Visits at Which Benzodiazepines Were Prescribed: Findings From 2014–2016 National Ambulatory Medical Care Survey [Internet]. National Health Statistics Reports; 2020 [cited 2021Nov3]. Available from: https://www.cdc.gov/nchs/data/nhsr/nhsr137-508.pdf

Jeetu G, Girish T. Prescription drug labeling medication errors: a big deal for pharmacists. J Young Pharm. 2010 Jan;2(1):107-11. doi: 10.4103/0975-1483.62218. PMID: 21331202; PMCID: PMC3035877.

The car crashes occurring on December 24 and December 31 due to impaired driving account for approximately 50% of all traffic fatalities a year.

National Drunk, Drugged Driving Prevention Month: A Pharmacist’s Role in Helping Patients Arrive Home Safely

November is nationally recognized as Diabetes Awareness Month. The primary goal for 2021 is for patients to become aware of their diabetes status and complete smaller healthy lifestyle changes to make a big difference in diabetes prevention and management.

 In the United States (US), there are more than 122 million people who have prediabetes or diabetes mellitus. Between 1999 to 2019 diabetes mellitus was the seventh leading cause of death.

 In 2018, the Centers for Disease Control and Prevention (CDC) estimated that 70% of those diagnosed with type 2 diabetes mellitus (T2DM) were 45 years of age or older.

 However, increased T2DM diagnoses are emerging among youth and young adult populations in the US with an estimate of around 5000 new cases each year, which warrants an increased need for awareness of early-onset T2DM.

Early-onset T2DM is defined as T2DM occurrence in patients younger than 45 years of age. Its pathophysiology resembles later-onset T2DM with similar non-autoimmune beta-cell failure and insulin resistance; however, early-onset T2DM pathophysiology is uniquely characterized by rapidly progressive beta-cell decline and accelerated advancement of diabetes complications.

 A clinical observation from a secondary care cohort reveals that the early-onset T2DM patients had a substantial increase in diabetic complications like cardiovascular events (37.2%), retinopathy (59.3%), and neuropathy (53.1%) when compared to later-onset T2DM.

 Early-onset T2DM is a more aggressive diabetic phenotype with a higher relative risk of cardiovascular mortality.

 Furthermore, a study analyzing the outcomes among this age-group concluded that a much higher proportion of young adults with T2DM required insulin treatment (18 vs. 11%, P < 0.001) and that younger adults with T2DM had an eightfold higher overall hazard of developing any macrovascular disease relative to control subjects (HR 7.9, 95% CI 4.8–13.0) compared with only a fourfold increased hazard in the usual-onset T2DM group (HR 3.8, 95% CI 3.4–4.2).

 Despite this unique pathophysiology, prevention and management of early-onset T2DM can be successful—especially with the help of health care providers like pharmacists.

Based upon the increased risk of diabetic complications, prevention of early-onset T2DM is imperative in patients who have modifiable risk factors for its development. In adults aged 18-29 years old, there has been a 70% increase in obesity which parallels the 70% increase in T2DM diagnoses among adults aged 30-39 years old.

 In addition to obesity, preventable risk factors include a lifestyle of physical inactivity and a diet high in processed fats and carbohydrates.

 Pharmacists can help modify these patients’ lifestyles by providing patient education on small healthy changes like increased physical activity and more nutritious eating habits. However, there are certain risk factors that put patients at an increased risk for development of early-onset T2DM which are nonmodifiable. Nonmodifiable risk factors include age, gender, race, ethnicity, and family history of disease. T2DM prevalence triples from the ages of 10-14 years to 15-18 years, and adolescent girls have a 60% higher prevalence rate when compared to males.

 Additionally, disadvantaged racial and ethnic minorities are at the highest risk for uncontrolled T2DM among patients under 20 years of age. A cross-sectional analysis of data from a 6-center US study of diabetes in youth indicated that 43.8% of Native American Indian participants, 36.4% of Asian/Pacific Islander participants, and 27.4% of Hispanic participants were classified as having the poorest glycemic control (defined as HbA1C ≥ 9.5%) when compared to only 12.2% of non-Hispanic White participants falling into the same category.

 Despite the inability for pharmacists to help change these risks, pharmacists can still make an impact in these patients’ lives by identifying these factors, informing the patient, and counseling the patient on the importance of healthy lifestyles based on their increased risk.

Natalie Blanco was diagnosed with early-onset T2DM at 15 years of age. She recalls feeling lost and confused.

“My physician was using big words that I did not understand like ‘monitoring my blood glucose,’” Blanco said. “I was also overwhelmed by all the new information, and I felt like my diagnosis was all my fault due to being overweight.”

Blanco did not know how to manage her new medications or reduce her increased risk for complications until she transitioned through care with various pharmacists whom she recalls as the “most memorable and impactful healthcare provider” during her journey. She credits pharmacists for her continued control of her T2DM.

“They continuously educate and empower me to successfully manage my diabetes, which is why I pursued a career as a pharmacy technician,” Blanco said.

Blanco is just one of many patients for whom pharmacists play an irreplaceable role in the advocacy for and management of early-onset T2DM. Moreover, pharmacists can continue to be impactful providers for this patient population through recognizing risk factors, providing proper medication management, aiding in transitional care, identifying support groups, encouraging healthy lifestyle changes, and spreading awareness of early-onset T2DM for the month of November as well as every day beyond.

National Institute of Diabetes and Digestive and Kidney Diseases. [Internet]. National Diabetes Month 2021. U.S. Department of Health and Human Services; [cited 2021Oct2]. Available from: https://www.niddk.nih.gov/health-information/community-health-outreach/national-diabetes-month

National Center for Chronic Disease Prevention and Health Promotion. Diabetes and Prediabetes [Internet]. Centers for Disease Control and Prevention; 2020 [cited 2021Sep21]. Available from: 

https://www.cdc.gov/chronicdisease/resources/publications/factsheets/diabetes-prediabetes.htm

Centers for Disease Control and Prevention, National Center for Health Statistics. Underlying Cause of Death 1999-2019 on CDC WONDER Online Database, released in 2020. Data are from the Multiple Cause of Death Files, 1999-2019, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program; 2020 [cited 2021Sep1]. Available from:

National Diabetes Statistics Report 2020 [Internet]. US Department of Health and Human Services; 2020 [cited 2021 Aug 3]. p. 6. Available from: https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf

Nadeau KJ, Anderson BJ, Berg EG, Chiang JL, Chou H, Copeland KC, et al. Youth-onset type 2 diabetes consensus report: Current status, challenges, and priorities [Internet]. Youth-Onset Type 2 Diabetes Consensus Report: Current Status, Challenges, and Priorities. American Diabetes Association; 2016 [cited 2021Oct2]. Available from: https://care.diabetesjournals.org/content/39/9/1635

Gungor N, Arslanian S. Progressive beta cell failure in type 2 diabetes mellitus of youth. J Pediatr. 2004 May;144(5):656-9. doi: 10.1016/j.jpeds.2003.12.045. PMID: 15127006.

Song SH, Hardisty CA. Early onset type 2 diabetes mellitus: a harbinger for complications in later years--clinical observation from a secondary care cohort. QJM. 2009 Nov;102(11):799-806. doi: 10.1093/qjmed/hcp121. Epub 2009 Sep 4. PMID: 19734298.

Song SH, Hardisty CA. Early-onset Type 2 diabetes mellitus: an increasing phenomenon of elevated cardiovascular risk. Expert Rev Cardiovasc Ther. 2008 Mar;6(3):315-22. doi: 10.1586/14779072.6.3.315. PMID: 18327993.

Hillier TA, Pedula KL. Complications in young adults with early-onset type 2 diabetes [Internet]. Diabetes Care. American Diabetes Association; 2003 [cited 2021Sep21]. Available from: https://care.diabetesjournals.org/content/26/11/2999

Type 2 diabetes in children [Internet]. Mayo Clinic. Mayo Foundation for Medical Education and Research; 2020 [cited 2021Oct2]. Available from: https://www.mayoclinic.org/diseases-conditions/type-2-diabetes-in-children/symptoms-causes/syc-20355318

Dabelea D, Mayer-Davis EJ, Saydah S, Imperatore G, Linder B, Divers J, Bell R, Badaru A, Talton JW, Crume T, Liese AD, Merchant AT, Lawrence JM, Reynolds K, Dolan L, Liu LL, Hamman RF; SEARCH for Diabetes in Youth Study. Prevalence of type 1 and type 2 diabetes among children and adolescents from 2001 to 2009. JAMA. 2014 May 7;311(17):1778-86. doi: 10.1001/jama.2014.3201. PMID: 24794371; PMCID: PMC4368900.

Petitti DB, Klingensmith GJ, Bell RA, Andrews JS, Dabelea D, Imperatore G, Marcovina S, Pihoker C, Standiford D, Waitzfelder B, Mayer-Davis E; SEARCH for Diabetes in Youth Study Group. Glycemic control in youth with diabetes: the SEARCH for diabetes in Youth Study. J Pediatr. 2009 Nov;155(5):668-72.e1-3. doi: 10.1016/j.jpeds.2009.05.025. Epub 2009 Jul 29. PMID: 19643434; PMCID: PMC4689142.

Blanco, Natalie. Personal interview by Rachel Friend. 9 August 2021.

The primary goal for 2021 is for patients to become aware of their diabetes status and complete smaller healthy lifestyle changes to make a big difference in diabetes prevention and management.

National Diabetes Month: How Pharmacists Can Serve Impactful Roles in the Lives of Patients with Early-Onset T2DM 

Sepsis is a life-threatening infection that can quickly lead to tissue damage, organ failure, and even death. An estimated 18 to 31 million cases occur globally every year with 850,000 occurring in the United States.

 With the mortality rate of sepsis at up to 30%, it is the leading cause of death for patients in the ICU.

Sepsis can arise from any source of infection, with 2 of the most common sources being pneumonia and urinary tract infection.

The rapid progression of sepsis makes it imperative to diagnose and start goal-oriented treatments as soon as possible. It has been shown that patient survival rate decreases by 7.6% for every hour that antimicrobial therapy is delayed.

After sepsis is diagnosed, immediate care is indicated to prevent decompensation, organ damage, and death. A 5-step process called the 1-hour bundle was developed to facilitate rapid, goal-oriented treatment in sepsis situations. The 1-hour bundle presents a step-wise algorithm for the initial treatment of sepsis:

Start fluid resuscitation using crystalloid fluids at a dose of 20-30 mL/kg

The data show that proper recognition of sepsis indicators and adherence to goal-driven therapies decreases mortality and length of stay in the hospital. Pharmacists are ideally positioned to assist the health care team with achieving these goals and therefore improving patient outcomes.

Adherence to the 1-hour bundle has been shown to significantly reduce mortality from 20.4% without bundle adherence to 17.9% mortality with bundle adherence (p-value = 0.035).

 One study showed that patients who received antimicrobials within 1 hour of hypotension had a survival rate of 79.9%.

Furthermore, the choice of appropriate broad-spectrum antimicrobials is vital to patient survival. Results from another study investigating this topic showed that patients who received appropriate empiric therapy were 5 times as likely to survive compared to those who did not (52% versus 10.3%, p< 0.001).

Additionally, one 2-year study conducted at a teaching hospital showed that the management of patients admitted to the emergency department for sepsis decreases significantly when clinical pharmacists conduct consultations.

 During the 2-year study, 585 consultations were provided by pharmacists for patients with sepsis. These consultations included dosing recommendations (53%), addition of appropriate antibiotics (22%), and medication preparation (19%), with the main medication classes discussed being antibiotics (83%) and vasopressors (8%). In this way, pharmacists can impact the early management of patients with sepsis in multiple ways, especially in terms of the optimization of antibiotic selection and medication dosing.

Pharmacists have also proven to be valuable members of sepsis response teams and tend to improve adherence to early goal-driven therapy, leading to better patient outcomes. Several studies have shown that a pharmacist’s presence on a sepsis team has a statistically significant impact on the time to antimicrobial administration (0.61 hours versus 0.88 hours, p =0.001).

Additionally, pharmacists have been shown to have a significant impact on patients successfully receiving antimicrobials within 1 hour (100% versus 95%, p=0.025), patients receiving appropriate antimicrobials (97% versus 81%, p= 0.0008), and decreased mortality (4.8%, p=1.08).

Furthermore, one study showed that a pharmacist’s presence at bedside during initial sepsis treatment reduced the time from antimicrobial order to administration from 157 minutes to 54 minutes.

 In this way, the impact of the pharmacist extends beyond the bedside and clinical patient outcomes to other areas as well, including significantly reducing billing costs, extra drug charges, and extra laboratory charges, which helps to decrease the economic strain on hospitals and patients.

Sepsis is a serious disease that can culminate in organ damage and even death, if handled inappropriately, but there is clear evidence that with the right screening tools and policies, along with early goal-driven therapy, the risk of serious complications and mortality can be significantly reduced.

Currently, pharmacists take on several roles during patient management of sepsis. With such a rapidly progressing and deadly disease state, it is imperative to have proper strategies paired with interprofessional collaboration to increase positive patient outcomes when treating sepsis, with pharmacists playing a critical role on a sepsis response team.

Uffen JW, Oosterheert JJ, Schweitzer VA et al. Interventions for rapid recognition and treatment of sepsis in the emergency department: a narrative review. 

Cavanaugh JB, Sullivan JB, East N et al. Importance of Pharmacy Involvement in the Treatment of Sepsis. 

Milano PK, Desai SA, Eiting EA et al. Sepsis Bundle Adherence Is Associated with Improved Survival in Severe Sepsis or Septic Shock. 

The Western Journal of Emergency Medicine

Kumar A, Roberts D, Wood KE et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. 

Weant KA, Baker SN. Emergency Medicine Pharmacists and Sepsis Management. 

Moussavi K, Nikitenko V. Pharmacist impact on time to antibiotic administration in patients with sepsis in the ED. 

Sarani B, Brenner SR, Gabel B et al. Improving sepsis care through systems change: the impact of a medical emergency team. 

The Joint Commission Journal on Quality and Patient Safety

MacLaren R, Bond CA, Martin SJ et al. Clinical and economic outcomes of involving pharmacists in the direct care of critically ill patients with infections. 

Gawrys GW, Tun K, Jackson CB et al. The impact of rapid diagnostic testing, surveillance software, and clinical pharmacist staffing at a large community hospital in the management of Gram-negative bloodstream infections. 

Diagnostic Microbiology and Infectious Disease

Tarabichi Y, Cheng A, Bar-Shain D et al. Improving Timeliness of Antibiotic Administration Using a Provider and Pharmacist Facing Sepsis Early Warning System in the Emergency Department Setting: A Randomized Controlled Quality Improvement Initiative. 

Several studies have shown that a pharmacist’s presence on a sepsis team has a statistically significant impact on patient outcomes, with pharmacists taking on several roles during patient management.

Sepsis Week: Pharmacists’ Have a Critical Impact on the Treatment of Sepsis

New evidence is evolving every day on clinical outcomes and different treatment options for patients with underlying medical conditions who test positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes the coronavirus disease 2019 (COVID-19).

 Currently, there is conflicting primary literature on whether adult patients with a diagnosis of active cancer are at an increased risk of developing severe illness from SARS-CoV-2 infection, and the correlation of the concomitant disease states, as well as treatment, is not well understood.

According to the CDC, having cancer increases your risk of severe illness from COVID-19.

 Severe illness from SARS-CoV-2 infection is defined as hospitalization, admission to the intensive care unit (ICU), intubation or mechanical ventilation, and death.

 Owing to this conflicting evidence, a comprehensive systematic search of 12 cohort study results that assessed cancer comorbidity and risk of mechanical ventilation or death in patients with confirmed COVID-19 found that patients had a lower risk of mechanical ventilation and death than patients without cancer.

 However, the authors felt that because of limited numbers, larger studies that include various malignancies from different centers are needed. In contrast, in a large systematic meta-analysis encompassing 110 studies from 10 countries analyzed pooled in-hospital mortality risk of COVID-19 in patients with cancer, results showed the estimated risk was between 9% and 20% across all settings.

Among 904 patients hospitalized, the pooled mortality risk estimate of 14.1% was at least 5 times higher than the reported mortality risk of COVID-19 in nonelderly patients without underlying predisposing conditions across Europe and North America, which was 0.7% to 2.6%.4 Although there is conflicting primary literature, the CDC’s recent update should caution health care providers to take a closer look at this patient population. 

It is reasonable to presume that patients with concomitant cancer and COVID-19 are at a higher risk of complications because of the systemic immunosuppressive state caused by cancer and the therapy used to treat it.

 Results from a small, retrospective study performed in China evaluated 18 patients with cancer and a diagnosis of SARS-CoV-2 infection found that patients had 3.5 times the risk of requiring mechanical ventilation or ICU admission, compared with the general population without cancer.

 Though the study results showed that patients with cancer are at an increased risk of complications, the small sample size of patients prevented the investigation of specific cancer-associated risk factors for worse outcomes.

A much larger retrospective case-control study comprising 73.4 million patient electronic health records from 360 hospitals across the United States aimed to assess the risk of contracting COVID-19 among 13 common cancer types and the risks associated with adverse outcomes.

 Of the millions of records analyzed, 1200 patients had cancer and received a diagnosis with COVID-19 within 1 year of the study end-date, August 12, 2020. Overall, patients with cancer and COVID-19 had significantly worse outcomes (hospitalization, 47.46%; death, 14.93%) than patients with COVID-19 without cancer (hospitalization, 24.26%; death, 5.26%) (P < .001).

 They concluded that there was a synergistic effect between COVID-19 and cancer on death and hospitalization rates, but the underlying biological mechanisms for this synergy warrants further investigation.

Because the risk of developing severe illness from COVID-19 in patients with different types of cancer is not fully characterized, clinicians are attempting to dig deeper to find nuanced correlations.6 In a large cohort study performed across 14 hospitals in Hubei Province, China, from January 1, 2020, to February 24, 2020, 105 patients with cancer and 536 age-matched patients without cancer with confirmed COVID-19 were assessed for clinical characteristics and outcomes.

 Investigators found that the patients with cancer were more likely to have severe outcomes than the patients without cancer, largely due to the types of tumors. The findings suggested that lung cancer, metastatic disease, and hematologic malignancies may be associated with higher rates of COVID-19-related ICU admissions and mortality.

In terms of cancer therapy, different types of treatments such as immunotherapy, chemotherapy, targeted therapy, and surgery had independent influences on the severity of illness and mortality associated with COVID-19. In the study, patients receiving immunotherapy had the highest severity of illness and death rate. However, because of the wide range of treatments utilized in patients and the small number of patients receiving immunotherapy, conclusions were difficult to draw; therefore, a larger case population is warranted to understand this relationship better.

To further evaluate the effects of immunotherapy as cancer treatment, a multicenter, retrospective analysis of 113 patients with cancer and laboratory-confirmed COVID-19 across North America, Europe, and Australia aimed to shed light on the effects on mortality.

 Immunotherapy, or immune checkpoint inhibitors (ICIs), use substances to stimulate or suppress the immune system.

 In this study, ICIs utilized were PD-1 or PD-L1 inhibitors or a combination of PD-1 or PD-L1 plus a CTLA-4 inhibitor.

 A large percentage of the patient population was from Europe (64%), and about one-third (33%) were from North America. Symptoms, comorbidities, and medications, in addition to investigations and treatments implemented for COVID-19, were analyzed. Investigators sought to look at hospital and ICU admissions and mortalities. Overall, results showed that for hospital and ICU admission, 61% of patients were discharged, 12% stayed in the hospital, and 27% of those admitted died by the data cutoff of May 15, 2020. The analysis results concluded that 9 patients died and this was not attributed to treatment with immunotherapy. Overall, they concluded that patients who received immunotherapy within 12 months of testing positive for COVID-19 did not increase the risk of mortality in patients.

Considering patients with cancer and concomitant SARS-CoV-2 infection are more vulnerable to severe outcomes, managing their cancer therapy during the pandemic can be challenging for clinicians.

 Many patients with cancer may need aggressive treatment due to the nature of their underlying disease; however, the clinical effects of cancer therapy in conjunction with COVID-19 are not fully known, and what data are available provide conflicting results.

 A study performed at a hospital in New York City from March 2020 to April 2020 assessed clinical characteristics and outcomes from 309 patients with cancer who received cytotoxic chemotherapy within 35 days of a COVID-19 diagnosis.

 Results showed that receipt of cytotoxic chemotherapy was not associated with adverse COVID-19 outcomes.

 Further adding to these data, 2 large observational studies were performed in patients with cancer and a confirmed SARS-CoV-2 infection between March 2020 and April 2020. Results of this study found the primary end point of all-cause mortality was not increased due to recent cytotoxic chemotherapy or other anticancer treatment.

On the other hand, results from a study conducted in China of 205 patients with cancer and COVID-19 showed that receiving cytotoxic chemotherapy 4 weeks before symptom onset had a higher mortality rate.

 Study results also found that patients with hematological malignancies had a poorer prognosis than those with solid tumors. The authors concluded that the evidence might not strongly prove that the patients studied have a higher fatality rate than the general patient population, and clinicians should be cautious when deciding whether or not to use cytotoxic chemotherapy in these patients.

 Overall, it is challenging to compare these studies because they vary in their end points and their statistical methods.

In a prospective observational study of 928 patients across the United States, Canada, and Spain from the COVID-19 and Cancer Consortium database, authors expressed that these data strongly indicate that COVID-19 mortality in patients with cancer is mainly driven by advancing age and the presence of other noncancer comorbidities.

 As a result, they do not suggest that chemotherapy or anticancer treatments will necessarily increase the risk of mortality from COVID-19.

 Adding to these data, prospective observational study results in 800 patients with active cancer in the UK Coronavirus Cancer Monitoring Project (UKCCMP) found that mortality from COVID-19 in patients with cancer appears to be mainly driven by age, gender, and comorbidities.

 The study results could not identify evidence that patients with cancer on cytotoxic chemotherapy or other anticancer treatment are at an increased risk of mortality from COVID-19 disease compared with those not on active treatment. The UKCCMP is the first COVID-19 clinical registry that enables near real-time reports to frontline doctors about the effects of COVID-19 on patients with cancer, so these data are promising.

Overall, the question of whether to continue treatment for cancer in a patient with concomitant COVID-19 should be individualized to that patient, with currently no specific recommendations on whether to continue or discontinue cancer therapy due to the vast array of cancer diagnoses, treatment options, and current comorbidities.

 Currently, the CDC recommends that patients with cancer and COVID-19 have a conversation with their health care provider or care team to discuss the individual level of risk based on the patient’s current condition, treatment, and the level of transmission within their community.

As a pharmacist, it is extremely important to counsel patients with cancer who develop COVID-19 to keep taking medications or not alter their treatment plan without first talking to their health care provider. Although no guidelines are published on oncology pharmacy practice in the COVID-19 context, the French Society for Oncology Pharmacy advocates that hospital and community pharmacists be especially alert to the use of OTC treatments and complementary and alternative medicines, as the pandemic encourages self-medication, which can lead to drug-related problems and herb-drug interactions.

, is a PharmD candidate at Auburn University Harrison School of Pharmacy in Alabama; 

, is an inpatient pharmacist in Tuscaloosa, Alabama, and a faculty member with Auburn University in Arkansas. 

People with certain medical conditions. Centers for Disease Control and Prevention. Updated December 29, 2020. Accessed January 6, 2020. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html#cancer

Perni S, Milligan MG, Saraf A, et al. Treating the SARS-CoV-2-positive patient with cancer: A proposal for a pragmatic and transparent ethical process. 

The CDC recommends that patients with cancer and COVID-19 have a conversation with their health care provider or care team to discuss the individual level of risk based on the patient’s current condition, treatment, and the level of transmission within their community. 