The Pharm So Hard Podcast: An Emergency Medicine and Hospital Pharmacy Podcast

Ashley and Brooke Barlow grew up in the suburbs of Philadelphia in Huntingdon Valley, PA. Both received their Doctor of Pharmacy Degree from Jefferson College of Pharmacy.

Ashley’s current interests include cardiology, oncology, and critical care along with a goal to pursue a career in academia. Beyond her passion for pharmacy, she enjoys getting creative in the kitchen cooking healthy meals, putting her strength to the test with weight lifting, and exploring different landmarks while shooting photographs.

Brooke’s current interests include Critical Care, Infectious Disease, Oncology. Her interests outside of pharmacy include fitness, healthy cooking, photography, and twitter!

Together they’ve become most known for their love of teaching clinical pearls & creating infographics that are frequently used throughout the FOAM ED community.

Pharmacy is Family: Twins Live TheFitPharmacist Life!

• https://thefitpharmacist.com/pharmacy-is-family

Surviving Stress: Tips for Staying Sane through Pharmacy School and Beyond

• http://www.ashpintersections.org/2019/10/surviving-stress-tips-for-staying-sane-through-pharmacy-school-and-beyond/

The ABCs of LVADs for Pharmacists

• https://www.tldrpharmacy.com/content/the-abcs-of-lvads-for-pharmacists

Hypertensive Emergency: Pearls and Pitfalls for the ED Physician

• http://www.emdocs.net/hypertensive-crisis-pearls-and-pitfalls-for-the-ed-physician/

The post Episode 8: The Transition from Pharmacy School to Residency with the Pharmacy Twins Ashley & Brooke Barlow appeared first on The Pharm So Hard Podcast.

http://www.medicalhf.org/epharm/index.html

https://www.ahrq.gov/downloads/pub/advances2/vol4/Advances-fairbanks_20.pdf

https://www.ashp.org/-/media/assets/pharmacy-practice/resource-centers/emergency-care/Justification-referenced-document.ashx

https://www.ahrq.gov/news/newsroom/case-studies/cquips0802.html

https://www.ashp.org/Pharmacy-Practice/Resource-Centers/Emergency-Care/Articles-and-Guidelines/Establishing-Emergency-Medicine-Pharmacy-Services-and-Medication-Safety

https://www.ashp.org/Pharmacy-Practice/Resource-Centers/Emergency-Care/Articles-and-Guidelines

The post Episode 7: Implementing and Expanding ED Clinical Pharmacy Services with Nicole Acquisto appeared first on The Pharm So Hard Podcast.

1. Opioid Sparing – providing multi – modal medications that limit the use and supply of opioids
2. Opioids – a class of drugs that act in the nervous system to produce feelings of pleasure and pain relief.
3. Opioid Addiction – a long-lasting (chronic) disease that can cause major health, social, and economic problems.
4. Opioid and Pain Stewardship – the standardization of best practices to identify the best treatment options for pain management to limit the use and supply of opioids.
5. PDMP – prescription drug monitoring program

1. The opioid crisis and the need for Opioid and Pain Stewardship program is widely recognized
2. Limited evidence on the structure of opioid and pain stewardship models for health-systems in the literature
3. Some level of recommendations exist from accrediting and professional organizations
4. Some success stories of implementing a pain stewardship committee and a pharmacist-led pain-management initiative

1. CDC promotes integrated, collaborative pain management and practice models that include pharmacists
2. NQP Opioid Stewardship action team has pharmacy involvement
3. ASHP advocates for the roles of a pharmacist in the opioid crisis

1. Intermountain Healthcare (stop, caution, go approach)
   1. Stop > avoid prescribing long acting opioids for acute conditions & dose > 50 mg morphine equiv/day
   2. Caution > patients at risk for overdose or abuse
   3. Go> prescribe lowest effective, integrate multimodal therapies, patient education
2. VA Prescribing guidelines:
   1. Review PDMP, Limit day supply of opioids, encourage to consult pain mgmt., not prescribe long-acting opioids
   2. A 500 bed hospital recognized in APhA for their program
   3. Pharmacy led program > receive pain mgmt. consults and run daily reports
   4. From 2013-2015  > Pharmacists have made 2,267 interventions, which Estimated an indirect cost avoidance of $2.7 million
   5. Initially executing 16 consults per month >  45 consults per month
   6. 59% reduction in opioid-associated rapid response calls and code blues
   7. An overall reduction in the use of high-risk medications on patients

Electing a physician champion, Engaging executives, establishing a committee, and creating a pharmacy-led program

1. Martin L, Laderman M, Hyatt J, Krueger J. Addressing the Opioid Crisis in the United States. IHI Innovation Report. Cambridge, Massachusetts: Institute for Healthcare Improvement; April 2016
2. Bentley E.D. Pain Management Stewardship. ASHP Leadership Conference. Dallas, Tx. October 14, 2018.
3. Dowell D, Haegerich, TM, and Chou, Roger. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. Centers for Disease Control Recommendations and Reports / March 18, 2016 / 65(1);1–49.
4. Baker DW. The Joint Commission’s Pain Standards: Origins and Evolution. 2017. Oakbrook Terrace, IL: The Joint Commission. 
5. Johnson PE, Jorgensen JA. Pharmacy and the C-Suite: Managing the Interface.  Pharmacy Leadership Forum. http://www.ashpmedia.org/pai/csuitetoolkit/ (Accessed 2018 July 25)
6. American Physical Therapy Association. APTA Contributes to New ‘Playbook’ on Pain Management and Opioid Stewardship. APTA. http://www.apta.org/PTinMotion/News/2018/03/12/NQFOpioidPlaybook/. Accessed November 15, 2018.
7. Erickson, A.K. (2015). Knocking out pain: Hospital pharmacists launch new approach to pain management. Pharmacist.com. Accessed November 15, 2018.  https://www.pharmacist.com/article/knocking-out-pain-hospital-pharmacists-launch-new-approach-pain-management.

The post Episode 6: Opioid Stewardship Part 2 with Oscar Santalo and Olga Ivanova appeared first on The Pharm So Hard Podcast.

1. Opioid Sparing – providing multi – modal medications that limit the use and supply of opioids
2. Opioids – a class of drugs that act in the nervous system to produce feelings of pleasure and pain relief.
3. Opioid Addiction – a long-lasting (chronic) disease that can cause major health, social, and economic problems.
4. Opioid and Pain Stewardship – the standardization of best practices to identify the best treatment options for pain management to limit the use and supply of opioids.
5. PDMP – prescription drug monitoring program

1. More than 130 people die every day from an opioid-related overdose (1 person every 15 min)
2. In 2009 the number of opioid prescriptions increased by 68% reaching 202 million
3. In 2010 hydrocodone/APAP (Norco) was the most commonly prescribed drug in the U.S.
4. U.S. uses 99% of the world’s supply

1. Pain management is complicated
2. Classifying pain, treatment options, and lack of pain specialists
3. Regulatory firms and professional organizations have a significant role to play because of the guidelines they establish.

1. Martin L, Laderman M, Hyatt J, Krueger J.

The post Episode 5: Opioid StewardshipPart 1 with Oscar Santalo and Olga Ivanova appeared first on The Pharm So Hard Podcast.

• Dosing
  • Supraventricular tachycardia
    • adenosine 6 milligrams (mg) may be given over 1 to 2 seconds followed by a 20 milliliter (mL) rapid saline flush. If there is no response in 1 to 2 minutes, a 12 mg IV bolus dose may be repeated twice followed by saline flushes 

• Mechanism of Action
  • Slows impulse formation in the sinoatrial (SA) node, slows conduction time through the atrioventricular (AV) node, and can interrupt reentry pathways through the AV node.

• Pharmacokinetics
  • Onset:  20 to 30 seconds
  • Duration: less than 10 seconds 
  • Metabolism: Adenosine is rapidly taken up by most types of cells, including cellular elements of the blood (erythrocytes) and vascular endothelium, where it is rapidly degraded by deamination to inosine and subsequently to hypoxanthine
  • Elimination: Total plasma clearance occurs in less than 30 seconds following intravenous administration

Administration Technique

1. How to mix single syringe diluted adenosine?
   • Grab a 20-30 ml syringe.
   • Draw up the adenosine AND the normal saline in the same 20-mL syringe.
   • Administer via fast IV push (can be through a running IV line).

Title: McDowell M, Mokszycki R, Greenberg A, et al. Single Syringe Administration of Diluted Adenosine. Acad Emerg Med. 2019 Oct 30. [ePub ahead of print]. [PMID 31665806]

• Methods
  • Single center, prospective, observational study was conducted from November, 1, 2016 through February 28, 2018 conducted at Advocate Christ Medical Center in Oak Lawn, IL
  • The physician would identify patients with SVT and would inform the pharmacist of their preferred adenosine administration method. The selection of the administration method was solely up to the provider regardless of admission into the study.
  • There were 26 patients in the single-syringe group and 27 patients in the traditional method group.

• Results
  • Successful conversion to NSR with the first
    dose was higher in the SS arm 73.1% (95% CI, 0.55 – 0.91) to 40.7% (95% CI, 0.21 – 0.61) (non-inferiority, p=0.0176).
    • Successful conversion to NSR with up to 3 doses was also higher in the SS arm 100% (95% CI, 1.0 – 1.0) to 70.4% (95% CI, 0.52 – 0.89) (non-inferiority, p=0.0043).
    • One patient in the conventional TS arm suffered extravasation and phlebitis compared to none in the SS arm.
• Conclusions
  • The SS administration method is simple and no less effective than the TS method.
  • Further randomized control studies should be completed to validate these results.

null
• Comments from the author

• “One thing I wish we had prospectively evaluated was how satisfied the RNs were with the novel method.”
• Another thing that I wish we could have worked in was the number of patients who presented multiple times during the study period
• When patients showed up for their 3rd or 4th SVT they would ask us for the SS method

• Other FOAM Posts
  • https://www.aliem.com/2019/10/trick-of-trade-combine-adenosine-single-syringe/

• References
  • Page RL, Joglar JA, Calwell MA, et al. 2015 ACC/AHA/HRS guidelines for the management of adult patients with supraventricular tachycardia: Executive summary. Heart Rhythm 2016;13(4):e92-e135
  • Ketkar VA, Kolling WM, Nardviriyakul N, et al. Stability of undiluted and diluted adenosine at three temperatures in syringes and bags. Am J Health Syst Pharm 1998;55(5):466-70. [PMID 9522931]
  • Kaltenbach M, Hutchinson DJ, Bollinger JE, et al. Stability of diluted adenosine in polyvinyl chloride infusion bags. Am J Health Syst Pharm 2011;68(16):1533-6. [PMID 21817085]
  • Lopez-Palop R, Saura D, Pinar E, et al. Adequate intracoronary adenosine doses to achieve maximum hyperaemia in coronary functional studies by pressure derived fractional flow reserve: a dose response study. Heart 2004;90(1):95-6. [PMID 14676256]
  • Choi SC, Yoon SK, Kim GW, et al. A convenient method of adenosine administration for paroxysmal supraventricular tachycardia. J Korean Soc Emerg Med 2003;14(3):224-7.
  • Helleman K, Kirpalani A, Lim R. A Novel Method of Intraosseous Infusion of Adenosine for the Treatment of Supraventricular Tachycardia in an Infant. Pediatric Emerg Care 2017;33(1):47-8. [PMID 28045841]

The post 5-Minute Pharmacy Pearl: Single Syringe of Diluted Adenosine for Termination of SVT appeared first on The Pharm So Hard Podcast.

Episode 4 Description: In this episode of Pharm So Hard, Oscar Santalo PharmD, MBA, MHA, BCPS with his learner Darla Quevedo PharmD 2021 candidate from the University of Florida School Of Pharmacy discuss drug trends for 2019 – 2020.  Here they discuss the Top 25 drugs by expenditures in nonfederal hospitals in 2018, the rise of biosimilars & specialty drugs, and medications coming off of patent.  

• Introduction
  • Overall pharmaceutical expenditures in the United States grew 5.5% in 2018, compared to 2017, for a total of $476.2 billion
  • Nonfederal hospitals accounted for $35.8 billion in prescription expenditures in 2018, a 4.8%

• What is the importance/relevance of this topic to pharmacy administration and pharmacy practice overall?
  • Factors driving growth: (1) purchases of new products that were not available previously, (2) price changes of existing agents, including both brand and generic drugs, and (3) changes in the volume of purchases (reflecting changes in utilization)
  • High growth in expenditures for older generics: (1) drug shortages leading to demand-related price increases or shifts in utilization to the branded products, (2) product discontinuations due to either manufacturing issues or business decisions

• Major Endpoints
  • 59 NMEs and 7 biosimilars approved in 2018
  • Specialty drug expenditures increased by 11.1% in 2018 compared to 2017, a rate is faster than the overall market growth rate of 5.5%.
  • Among the top 25 categories with the greatest increases in expenditures in 2018 compared to 2017 were drugs for neurologic disorders (32.4%), immunologic agents (18.0%), contraceptives (17.7%), and hormones (12.5%)
  • Hospitals/clinics must also be aware of drugs that have potential patent expiration each year. Generic forms of these drugs may be in the pipeline which are cheaper alternatives to their brand counterparts

References:

1. Schumock GT, Stubbings J, Hoffman JM, et al.

The post Episode 4: Drugs Trends in Pharmacy with Oscar Santalo and Darla Quevedo appeared first on The Pharm So Hard Podcast.

In this episode of Pharm So Hard, Jimmy Pruitt, Pharm.D and Kyle Hultz, Pharm.D discuss the excitement and the challenges of transitioning from residency to the role of an emergency medicine clinical pharmacist.

The post Episode 3: Transitioning from Resident to EM Pharmacy Practitioner with Kyle Hultz appeared first on The Pharm So Hard Podcast.

Coagulation factor Xa [recombinant], inactivated-zhzo ( Andexxa )

• Andexanet alfa binds and sequesters the FXa inhibitors rivaroxaban and apixaban. In addition, andexanet alfa inhibits the activity of Tissue Factor Pathway Inhibitor (TFPI), increasing tissue factor-initiated thrombin generation.

• Reference & Additional Readings
  • Connolly SJ et al. Full Study Report of Andexanet Alfa for Bleeding Associated with Factor Xa Inhibitors. N Engl J Med. 2019 Apr 4;380(14):1326-1335
  • Andexxa (andexanet alfa) [prescribing information]. South San Francisco, CA: Portola Pharmaceuticals, Inc; May 2018.
  • Ghadimi K et al. Andexanet alfa for the reversal of Factor Xa inhibitor related anticoagulation. Expert Rev Hematol 2016; 9: 115-22.
  • Lexi-comp: Andexanet alfa Prescribing Information. Last Updated 6/1/18. Assessed September 27, 2019.
  • FDA Approval Letter – ANDEXXA. May 3, 2018. https://www.fda.gov/downloads/BiologicsBloodVaccines/CellularGeneTherapyProducts/ApprovedProducts/UCM606693.pdf. Assessed September 27, 2019.

Related Foam Posts

• https://emcrit.org/emcrit/issues-andexanet/
• https://first10em.com/andexanet-alfa/
• http://www.emlitofnote.com/?p=4384
• https://www.stemlynsblog.org/jc-reversal-of-noacs-andexanet/
• http://www.emdocs.net/reversal-of-anticoagulation-an-update/

The post Episode 2: Factor Xa Inhibitor Reversal Using Andexxa with Gary Peksa appeared first on The Pharm So Hard Podcast.

• Profilnine SD and Bebulin
  1. Unactivte PCC, 3-Factor
  2. Cogulation Factors
     1. II, IX, X
• Kcentra
  • Unactivated PCC, 4-Factor
  • Coagulation Factors
    • II, VII, IX, X
• FEIBA
  • Activated PCC, 4-Factors
  • Coagulation factors
    • II, VII, IX, X
• NovoSeven
  • Activated factor VIIa
  • Coagulation Factors
    • Recombinant VIIa

• Dabi A, et al. Crit Care Res Pract 2018;4907164.
• Smith S, et al. J Thromb Thrombolysis. 2019 Apr 2.
• Berger K, et al. J Intensive Care Med. 2019 Apr 14.
• Dager WE, et al. Thromb Res. 2019 Jan;173:71-76.
• Schulman S, et al. Thromb Haemost 2018;118:842 51.
• Santibanez M, et al. J Crit Care 2018;48:183 90
• Allison TA, et al. J Intensive Care Med 2018 Epub ahead of print].
• Tao J, et al. J Intensive Care 2018;6:34.
• Majeed A, et al. Blood 2017;130:1706 12.
  

The post Episode 1: Factor Xa Inhibitor Reversal Using PCC with Brian Gilbert appeared first on The Pharm So Hard Podcast.