Helixtalk - Rosalind Franklin University's College Of Pharmacy Podcast

In this episode, we discuss the concerns of QTc prolongation, which can cause a fatal arrhythmia called torsades de pointes (TdP). We cover the difference between QT and QTc, how to interpret a QTc (and when it is inaccurate), common medications that prolong QTc, and how pharmacists can evaluate the risk of QTc/TdP in patients who are receiving QTc-prolonging therapies. Key Concepts The QTc interval is the QT interval that has been “corrected” for heart rate. In nearly all cases, when describing a QT interval, it should be expressed as the QTc. Although a prolonged QTc is usually defined as a QTc exceeding 450-480 msec, the risk of torsades de pointes (TdP) begins to become concerning when the QTc is more than 500 msec, 15-20% longer than baseline, or if the QTc has increased by more than 60 msec. Vaughan-Williams Class III antiarrhythmics are most implicated in QTc prolongation and TdP risk. These therapies include sotalol, dofetilide, and dronedarone. Although amiodarone is a class III antiarrhythmic, its

In this episode, we will discuss the most important updates from the American Diabetes Association’s 2023 Standards of Care in Diabetes. Key Concepts The first-line therapy for type II diabetes is based on whether the primary goal of therapy is cardiorenal benefit (reduced risk of ASCVD, heart failure, or CKD) or glycemic and weight goals. For cardiorenal benefit, GLP1 receptor agonists and SGLT2 inhibitors are heavily emphasized. For glycemic control and weight gain, GLP1 receptor agonists (or GLP1/GIP in the case of tirzepatide) have a very favorable effect on weight loss and glycemic control. While metformin is still mentioned, it is no longer the sole, first-line therapy for type II diabetes. For patients with diabetes and a high risk of ASCVD (20% or higher), high-intensity statins, ezetimibe, and/or PCSK9 inhibitors are recommended to achieve an LDL less than 70 mg/dL. In patients with a history of ASCVD events, these same therapies are used to achieve a recommended LDL goal of less than 55 mg/dL. Amon

In this episode, we review clinical pearls and common pitfalls of immunosuppression regimens for organ transplantation with a particular focus on tacrolimus and mycophenolate. Key Concepts Most recipients of an organ transplantation will be on a two or three drug regimen. The most common regimen is tacrolimus and mycophenolate with/without a corticosteroid. Tacrolimus is hepatically eliminated and susceptible to CYP3A4 and PGP drug interactions. Particularly at higher drug concentrations, it is associated with nephrotoxicity and neurotoxicity (among several other adverse effects). Mycophenolate is unstable in the acidic environment of the stomach. The two formulations on the market are CellCept (which uses a prodrug, mycophenolate mofetil, that is converted in the liver to an active compound) and Myfortic (an enteric-coated formulation of mycophenolic acid, which releases after exiting the stomach). The intensity of an immunosuppression regimen is determined by numerous factors, including the type of organ,

In this first ever CE episode, we discuss the A-Zs of continuous glucose monitors (CGMs). In specific, our learning objective for the CE are: Describe commonly available types of continuous glucose monitors (CGMs) in the US market and the features and capabilities of these devices. Summarize the evidence and guideline recommendations for use of CGMs in the management of diabetes. Identify the role of the pharmacist in the selection of CGMs and provision of education to patients and providers. Interpret the ambulatory glucose profile (CGM data output) and recommend changes in antihyperglycemic regimen for a patient. ACPE-Accredited Pharmacist CE (1.0 hrs) To obtain CE credit for a $5 fee, visit the following link: https://rfums.wufoo.com/forms/z1qzh5vf0ggr832/. Once payment is successful, you will be redirected to our CE partner (CE Impact) to complete an evaluation and to earn 1.0 hour of CE credit. CE is available for 12 months after episode publication. Key Concepts There are two main types of st

In this episode, we interview Dr. Shannon Rotolo and Dr. Alex Berce regarding Illinois and Wisconsin drug repository programs – these are programs that allow certain medications to be donated to participating sites and then redistributed to patients at a very low dispensing cost. Key Concepts Drug repository programs allow participating sites to accept certain donated medications and redistribute these medications to needy patients at a very low dispensing cost. Drug repository programs are regulated by state law and the specifics of the process do vary by state. In Illinois and Wisconsin, donated medications must be in their original containers with tamper-evident packaging, cannot be controlled substances, and must have a 90-day expiration window at the time of donation. Pharmacists can play an important role in advocating for patients and the profession of pharmacy. The involvement of pharmacists in legislation is critical to make sure that new laws are actually “functional” and can achieve their intended

In this episode, we discuss the evidence, safety, and place in therapy of Auvelity® (dextromethorphan-bupropion), a newly approved antidepressant with a unique mechanism of action and interesting pharmacokinetic considerations. Key Concepts Auvelity® (bupropion-dextromethorphan) was FDA approved in 2022 for major depressive disorder (MDD). The bupropion component inhibits CYP2D6 metabolism and increases serum concentrations of dextromethorphan. The proposed mechanism of benefit in MDD is via dextromethorphan (as an NMDA antagonist) and possibly with bupropion (as a dopamine/norepinephrine reuptake inhibitor). Although the bupropion component in Auvelity® is being used for its drug interaction, the dose is a therapeutic dose and carries several warnings and precautions, including the risk of seizure and hypertension. In short (6-week) clinical trials, Auvelity® improved depression symptoms quickly (within 1-2 weeks), which is faster than many other antidepressants. Auvelity® is associated with dizziness, anxi

In this episode, we highlight important changes to the 2023 GOLD Guidelines for COPD. In particular, we discuss a revision to the GOLD group classification system and the preferred initial therapies in patients with COPD. Key Concepts The newest GOLD COPD guidelines now recognize three GOLD groups – “A”, “B”, and “E”. Group “E” (formerly groups C and D) are patients with frequent exacerbations (defined as 2 or more in the past 12 months or 1 exacerbation requiring hospitalization). For group “E” patients, the preferred initial inhaler regimen is a LABA+LAMA. Triple therapy (LABA+LAMA+ICS) can be considered if blood eosinophils are elevated. “Triple therapy” (LABA+LAMA+ICS) has gained traction based on the IMPACT and ETHOS trials – this regimen reduced exacerbations and mortality compared to LABA+LAMA and LABA+ICS. With an exploding market of new COPD inhalers, the role of the pharmacist is even more critical to help identify affordable medications and provide patient education for proper inhaler technique.

In this episode, we will discuss all things peripheral arterial disease – definitions, staging, clinical presentation, risk factors, goals of therapy, and guideline-directed medication therapy recommendations including the newest evidence for the use of DOACs. Key Concepts Addressing modifiable risk factors (weight loss, smoking cessation, blood pressure and blood glucose control, dyslipidemia, structured exercise program, etc.) are recommended for the treatment of PAD. Single antiplatelet therapy with either aspirin 81 mg or clopidogrel 75 mg daily are recommended in patients to reduce stroke, MI and other vascular deaths in symptomatic (1A) and asymptomatic patients (IIa- C-EO). Rivaroxaban 2.5 mg BID, when added to aspirin 81 mg daily, is superior to aspirin alone in preventing composite outcome of stroke, MI, and CV death in PAD patients with recent revascularization surgery for PAD but increases the risk of major bleeding. In the absence of heart failure, cilostazol is effective in improving symptoms, q

In this episode, we review the management of a patient with hypokalemia, including both inpatient and outpatient supplementation with potassium chloride supplements and what dosage forms are available for potassium repletion. Key Concepts Most diets will provide sufficient potassium to avoid hypokalemia. Hypokalemia usually occurs due to drug therapy (such as diuretics) or GI losses from severe vomiting or diarrhea. In patients with chronically low potassium, supplements are dosed to increase dietary intake of potassium by about 20-40 mEq per day. For acute repletion, 10 mEq of potassium should increase serum potassium by about 0.1 mEq/L. Over-the-counter potassium (as potassium gluconate) contains a very small amount of potassium (2.5 mEq). Potassium chloride powders and liquids (like salt substitutes) taste terrible and are poorly tolerated. Most patients will replete potassium via slow-release tablets (Klor-Con or Klor-Con M) or via potassium chloride IV infusions. Most IV fluids do not contain any potass

In this episode, we will define Digital Health, its categories and examples, describe how pharmacists are involved in DH practice, opportunities and limitations and future of DH. We will also discuss what implications DH has for educators, educational institutions, student pharmacists, pharmacists, and practice of pharmacy in general. Key Concepts Digital Health is currently a broad umbrella category that uses mobile health, telehealth, web-based platforms, personalized medicine, and IT to provide scalable patient care. There are several focused areas within DH that would impact pharmacy practice by warranting pharmacist oversight or collaborative insights. There is positive data for pharmacist-led DH interventions using mobile apps and web-based tools, but the use of telehealth modality has mixed results. Pharmacists need to stay current in their knowledge and skills for utilizing DH tools in integrative and collaborative patient care. References Aungst TD, Franzese C, Kim Y. Digital health implications f

In this episode, we invite Dr. Amir Ali, PharmD, BCOP to discuss with us the pathophysiology, risk factors, prevention, and treatment clinical pearls of tumor lysis syndrome TLS). Key Concepts TLS is caused by rapid cell death of cancerous cells that results in intracellular contents “spilling” into the blood – this leads to high serum uric acid, high serum potassium, high serum phosphate, and LOW calcium. These laboratory abnormalities cause acute kidney injury (via crystal formation in the kidney), arrhythmias (from hyperkalemia), and seizures (from high phosphate and low calcium). Patients at highest risk for TLS are those with hematologic malignancies (lymphomas and leukemias), especially if WBC or LDH labs are very high. Prevention is the Key! The primary prevention approach for TLS is hydration, allopurinol, and sometimes a low dose of rasburicase. The treatment of TLS involves more aggressive hydration and rasburicase. References Coiffier B, Altman A, Pui CH, Younes A, Cairo MS. Guidelines for the m

In this episode, we review Paxlovid (nirmatrelvir/ritonavir) from the perspective of its pharmacology, efficacy, safety, pharmacists’ authority to prescribe, drug interactions, and rebound symptoms after Paxlovid therapy. Key Concepts Paxlovid is the preferred outpatient therapy for COVID-19 in patients at high risk for progressing to severe COVID-19. It likely has similar efficacy to IV monoclonal antibodies and IV outpatient remdesivir but differences in vaccination rates and patient populations makes a direct comparison difficult. The 5-day course of Paxlovid is generally well tolerated. “Paxlovid mouth” (dysgeusia) is relatively common and is characterized by a terrible metallic or garbage-like taste in the mouth during therapy. As of July 2022, licensed pharmacists have the authority to assess patients for Paxlovid and prescribe the therapy; however, Medicare/Medicaid reimbursement has not clearly established how reimbursement of clinical services can occur. “Rebound” COVID-19 symptoms may or may not be

In this episode, we will discuss mechanism, pharmacokinetics, efficacy, safety, and possible place in therapy for tirzepatide (Mounjaro), a new treatment for type 2 diabetes. Key Concepts Tirzepatide is a novel GIP and GLP-1 receptor agonist resulting in glucose-dependent secretion of insulin and a decrease in glucagon secretion. This medication was FDA approved in May 2022 for the treatment of type 2 diabetes as an adjunct to diet and exercise. It is available as a long-acting once weekly pen injection to be administered subcutaneously. Current efficacy data exist from a 40-week trial which showed that tirzepatide was superior to semaglutide in A1c reduction and weight loss. The most common adverse effects of tirzepatide include GI concerns such as nausea, vomiting, and diarrhea as well as hypoglycemia. References Frias JP, Davies MJ, Rosenstock J, et al. Tirzepatide versus Semaglutide Once Weekly in Patients with Type 2 Diabetes. N Engl J Med. 2021;385:503-515. https://www.nejm.org/doi/full/10.1056/NEJMo

In this episode, we will discuss the rationale behind the FDA approval of two new pneumococcal conjugate vaccines (PCV20 and PCV15), the characteristics of these vaccines, their place in therapy as recommended by the ACIP, and subsequent CDC immunization schedule changes. Key Concepts Pneumococcal disease is mainly caused by various serotypes of Streptococcus pneumoniae and presentation can vary from mild forms (sinusitis, otitis media) to more severe (pneumonia, bacteremia, or meningitis). Previously we used PCV13 and PPSV23 vaccines for adults ages 18 years and older for prevention of pneumococcal disease, but the recommendations were rather complicated based on age, underlying condition/immune status, and vaccination status.  Two new conjugate-type pneumococcal vaccines, PCV20 (Prevnar 20) and PCV15 (Vaxneuvance) are now approved by the FDA and were recently added to the CDC’s adult immunization schedules. These updated recommendations are more simplified where adults with high-risk conditions and those a

In this episode, we “deep dive” into diltiazem, describing its most important drug facts, pharmacology and medicinal chemistry, pharmaceutics, AB compatibility, and important medication safety issues. Key Concepts Diltiazem is a non-dihydropyridine calcium channel blocker (CCB). This type of CCB reduces both heart rate and blood pressure whereas dihydropyridine CCBs only reduce blood pressure. Diltiazem has numerous dosage forms (IV, immediate release tablets, and extended-release products). Extended-release products are always dosed once or twice daily. Historically there were a significant number of extended-release capsules with a variety of brand names and AB-compatibility. Today, only a few branded products still exist in the US market (Cardizem CD, Cartia XT, Cardizem LA, Tiazac, Taztia XT). The FDA Orange Book describes “AB” compatibility, which outlines whether one formulation is therapeutically equivalent to another formulation. Depending on state law, pharmacists can use AB compatibility codes to a

In this episode, the hosts of the HelixTalk reflect back on the history and making of HelixTalk to commemorate the 150th episode. We review each of our three favorite episodes and with a brief reflection on the episode content. We have come a long way from where we began and it is all thanks to the wonderful listeners and contributors who have a common thing in mind: a quest and thirst for knowledge! Links to Previous Episodes: #50 - Three shocking recommendations from CHEST 2016 that will blow your mind (https://www.rosalindfranklin.edu/academics/college-of-pharmacy/helixtalk/helixtalk-episode-50--three-shocking-recommendations-from-chest-2016-that-will-blow-your-mind/) #29, 30, and 31 - Therapeutic Drug Monitoring (https://www.rosalindfranklin.edu/academics/college-of-pharmacy/helixtalk/helixtalk-episode-29--therapeutic-drug-monitoring-i/, https://www.rosalindfranklin.edu/academics/college-of-pharmacy/helixtalk/helixtalk-episode-30--therapeutic-drug-monitoring-ii/, https://www.rosalindfranklin.edu/academ

In this episode, we will cover a complete overview of definition, diagnosis, treatment and monitoring of iron deficiency anemia (IDA). Key Concepts Iron-deficiency anemia (IDA) is the most common type of nutritional anemia. The most common risk factors are insufficient dietary intake, malabsorption, and increased requirement states like pregnancy or blood loss. Serum ferritin serves as the most confirmatory lab test for diagnosis of IDA. A low serum ferritin level usually indicates the presence of IDA. Other iron studies and CBC can be helpful in diagnosing IDA as well.  Generally oral iron therapy is a well-accessible, inexpensive, safe, and effective approach for IDA treatment. Almost all PO options are equally effective and safe. Gastrointestinal adverse effects are common and can sometimes limit further dosing.  Intravenous iron therapy is generally reserved for patients who are refractory or intolerant to PO treatment, have malabsorption of PO iron therapy, or have other health conditions such as chroni

In this episode, we interview Hetal Patel, PharmD and RFUMS COP Alumni, regarding her career path that eventually led her to open Lebanon Family Pharmacy in TN in 2021. We discuss the challenges and opportunities of starting a new independent pharmacy and what the future of independent pharmacy looks like. Key Concepts Starting a new, independent pharmacy requires substantial planning 8 to 12 months before the pharmacy’s doors even open. New pharmacy owners need to consider a variety of factors such as location, type of building, a business plan with financial analysis, a variety of building and pharmacy inspections, paperwork and government approvals, and so much more. PSAOs (pharmacy services administrative organizations) can be helpful, especially for new pharmacy owners, to serve as a liaison between the pharmacy and PBMs (pharmacy benefit managers) to negotiate reimbursement contracts. As owners gain more experience, there may be financial advantages to not using PSAOs and negotiating with PBMs directly

In this episode, we review new updates and key concepts from the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. This guideline is newly published (April 2022) and is a full update of the 2013 guidelines and the 2017 focused update for heart failure. Key Concepts Heart failure is classified as HFrEF (heart failure with reduced ejection fraction = 50% with increased LV filling pressures). Most drug therapy recommendations are similar for HFrEF, HFimpEF, and HFmrEF whereas HFpEF therapies are different. The 2022 AHA/ACC/HFSA heart failure guidelines now recommend SGLT2 inhibitors, such as dapagliflozin and empagliflozin, in patients with HFrEF, HFmrEF, and HFpEF. The 2022 AHA/ACC/HFSA heart failure guidelines continue to prefer ARNi, such as sacubitril/valsartan (Entresto), over ACE inhibitors and ARBs in patients with HFrEF. Based on the PARAGON-HF trial, ARNi is also recommended in those with HFpEF albeit with a weak recommendation. Avoiding excessive dietary sodium is reasonable to reduce c

In this episode, we discuss six newer antibiotics that target multidrug resistant gram negative bacteria with Dr. Christie Bertram, PharmD, BCIDP. We review common resistance mechanisms, particularly to carbapenems, and highlight the current role in therapy for the following antibiotics: ceftolozane/tazobactam (Zerbaxa®), ceftazidime/avibactam (Avycaz®), meropenem/vaborbactam (Vabomere®), imipenem/cilastatin/relebactam (Recarbrio®), cefiderocol (Fetroja®), and eravacycline (Xerava®). Key Concepts Ceftolozane/tazobactam (Zerbaxa®) is primarily used for multidrug resistant Pseudomonas; it does not cover carbapenemase-producing organisms and (despite the tazobactam) needs metronidazole for intra-abdominal anaerobic coverage. Ceftazidime/avibactam (Avycaz®) is primarily used to cover CRE (Carbapenem-resistant Enterobacterales) but also has activity for many other gram negatives except Acinetobacter. Meropenem/vaborbactam (Vabomere®) has similar coverage to Avycaz® but may provide coverage for certain KPCs (Klebs