Carla Dillon

Pre-operative and post-operative changes in CRP and other biomarkers sensitive to inflammatory status in patients with severe obesity undergoing laparoscopic sleeve gastrectomy

INTRODUCTION C-reactive protein (CRP) is often elevated in patients living with severe obesity (BMI≥35kg/m2). However, there is limited information on how CRP, and other inflammation responsive biomarkers, change in response to weight loss following laparoscopic sleeve gastrectomy (LSG). We studied how CRP, ferritin and albumin change following LSG surgery in relation to obesity, metabolic syndrome (MetS) ATPIII risk components and diabetes mellitus (DM). METHODS Laboratory parameters (including CRP) were examined in 197 patients prior to LSG, and at 6, 12, 18 and 24months. Changes in laboratory parameters, and laboratory investigations, were also examined in a 125 patient subgroup at both pre-LSG and at the 12month follow-up visit. RESULTS All patients had BMI≥35kg/m2. CRP levels positively correlated with BMI (r=0.171, p=0.016) and alkaline phosphatase (ALP; r=0.309; P<0.001), but negatively correlated with alanine aminotransferase (ALT; r=-0.260; P<0.001) and albumin (r=-0.358; P<0.001). LSG significantly reduced CRP and ferritin, which were maintained for at least 24months. At 12months post-LSG there was a significant decrease in weight (kgs) (p<0.001), CRP (p<0.001), ferritin (p=0.004), and various MetS risk components (p<0.001) but not albumin (p=0.057). Changes in CRP also correlated with changes in weight (r=0.233, p=0.018) and ALP (r=0.208, p=0.034) but not albumin (r=-0.186, p=0.058) or ferritin (r=0.160, p=0.113) after LSG. CONCLUSION The negative correlation between CRP and albumin levels in obesity may indicate a low grade inflammatory process affecting both. LSG related weight loss decreased CRP and ferritin, likely explained by improvement in inflammatory status.

Prevalence of medication management by community pharmacists in patients of a Newfoundland family medicine clinic.

Although the degree to which pharmacists may renew or adapt prescriptions varies widely by province, the overarching trend of expanded services is clearly growing.1-3 With the addition of reimbursement programs in some provinces1 and the introduction of prescriptive authority in others,2,4 there is clear growth in pharmacists’ scope of practice. As a result, pharmacists have more responsibility for and input into patient care. Medication management is an umbrella term that encompasses a variety of professional activities undertaken by a registered pharmacist to optimize safe and effective drug therapy outcomes for patients.5,6 Currently in Newfoundland and Labrador (NL), medication management includes providing an interim supply of medications, extending a prescription and adapting a prescription.6 The majority of Canadian pharmacists have the authority to provide these services; however, there are differences between provinces in what is permitted and how this authority is attained.7 In NL, both providing an interim supply and extending a prescription entail dispensing additional medication for a previously prescribed chronic therapy. When an interim supply is provided, the original prescription may have been filled at another pharmacy. An interim supply allows for a small quantity to be given that is usually less than one refill, to bridge the time needed for the patient to see his or her prescriber or to return to his or her usual pharmacy. When a prescription is extended, an additional refill of a 90-day supply or less is given for a medication previously filled at that pharmacy. Adapting a prescription includes changing the dosage form, regimen or quantity, filling in missing information and making a nonformulary generic substitution. These medication management services cannot be applied to a narcotic, controlled drug or targeted substance, including benzodiazepines.6 In 2010, changes to the NL Pharmacy Regulations permitted the use of medication management under the procedure outlined in the NL Pharmacy Board (NLPB) Standards of Pharmacy Practice.6,8 To provide this service, NL pharmacists must provide NLPB with a signed declaration indicating they have thoroughly read and understand the medication management standard of practice. As part of the fundamental requirements for performing medication management, NLPB states that in most instances the original prescriber or the patient’s primary health provider must be notified, preferably via faxing a standard form.6 In June 2012, the NL Prescription Drug Program (NLPDP) agreed to pay pharmacists for medication management services provided to NLPDP beneficiaries.9 The Ross Family Medicine Centre (RFMC) is an academic clinic in St. John’s, NL. Prescribers in this clinic include 5 family physicians, 1 nurse practitioner and family medicine residents. Although the RFMC provides care to patients of all ages, this clinic specializes in geriatric care. Medication management documentation received by the RFMC is scanned into patients’ electronic medical records. On January 28, 2013, the RFMC implemented a policy of referring patients to their community pharmacist for an interim supply or prescription extension if they ran out of medications prior to being able to see their prescriber. The change in policy was driven by the belief that this service would help to more effectively use prescribers’ time by reducing time addressing calls or faxes for medication refills, while maintaining continuity of treatment for patients. Currently, there are limited Canadian data on the use of interim supply and extending and/or adapting a prescription, and there is no information on these practices in NL. In the first year (2009) that this scope was in effect in British Columbia (BC), only 0.17% of prescriptions were renewed or adapted. Of those, 80% were prescription renewals.10 In contrast, when medication management labour costs among 10 BC pharmacists who were known high users of medication management were studied, adaptation or renewal was applied to 8.2% prescriptions over a 40-hour work period. Of those, only 47% involved renewing a prescription.11 Given the potential for optimization of patient care, a better understanding of the local prevalence of medication management use, including the frequency of specific medication management services, may lead to improvements in the process for pharmacists, prescribers and patients. The objectives of this study were to determine the prevalence of medication management use by NL community pharmacists in patients of the RFMC and to determine the frequency of the subcategories of medication management in this same population.