Emily L. Knezevich

Liraglutide-associated acute pancreatitis

PURPOSE A case of acute pancreatitis associated with liraglutide is reported. SUMMARY A 53-year-old African-American man (height, 185.4 cm; weight, 108.6 kg) with type 2 diabetes mellitus arrived at the emergency department (ED) with new-onset intolerable abdominal pain in the right upper quadrant and left upper quadrant that had appeared suddenly and lasted two to three hours. He had nausea but no vomiting, with tenderness in the epigastric region. In the ED, his serum amylase concentration was found to be extremely elevated (3,963 units/L), as was his serum lipase concentration (>15,000 units/L). In addition to type 2 diabetes, his medical history included hyperlipidemia, hypertension, peripheral neuropathy, erectile dysfunction, and obesity. His home medications included aspirin 81 mg orally daily, metformin 1000 mg orally every morning and 1500 mg every evening, simvastatin 80 mg orally daily at bedtime, tadalafil 20 mg orally as needed, glimepiride 4 mg orally twice daily, and liraglutide 1.2 mg subcutaneously daily. Two months before his arrival to the ED, the patients dosage of liraglutide was increased from 0.6 to 1.2 mg subcutaneously daily. Radiographic data were obtained, and acute pancreatitis was diagnosed. Liraglutide was discontinued indefinitely after ruling out elevated triglycerides as the cause of pancreatitis. The patient was initiated on standard therapy for acute pancreatitis and discharged eight days later with complete resolution of symptoms and normal laboratory test values. CONCLUSION A 53-year-old man with type 2 diabetes mellitus developed a probable case of liraglutide-induced acute pancreatitis after receiving the drug for approximately two months.

Medical management of adult transsexual persons

Gender identity disorder (GID), or transsexualism, is an increasingly recognized medical condition with an expanding body of medical literature to support the use of established therapeutic guidelines. Transsexualism can be effectively managed through exogenous cross‐sex hormone administration used to induce development of desired sex characteristics, as well as use of other agents, such as aldosterone antagonists, aimed at decreasing physical characteristics of the undesired sex. Many complications can arise with the use of the available therapies, and these must be considered before determining the appropriate course of action. This review describes methods, including both pharmacotherapy and surgical interventions, for effective medical management of both male and female adults with GID. In addition, specific goals of therapy as well as safety aspects with long‐term use of pharmacotherapeutic agents are discussed. This review also discusses some special considerations for treating patients with significant, yet common, comorbid diseases such as human immunodeficiency virus infection, acquired immunodeficiency syndrome, and viral hepatitis, as these conditions may complicate the clinical course and preclude some patients from using certain therapies. Pharmacist involvement in the management of transsexualism can be extremely beneficial to patients and other health care providers. Pharmacists can help determine the appropriate therapy, optimize dosages, monitor for adverse effects, and educate patients on what to expect during their therapy. Pharmacists should become knowledgeable about guidelines and current literature on transsexualism, understand the monitoring parameters for safe and effective therapy, and establish themselves as partners in the collaborative management of this disorder.

V-Go Insulin Delivery System Versus Multiple Daily Insulin Injections for Patients With Uncontrolled Type 2 Diabetes Mellitus

Type 2 diabetes mellitus affects over 29.1 million Americans, diagnosed and undiagnosed. Achieving and maintaining glycemic control for these patients is of extreme importance when working to prevent complications and improve quality of life for patients. The V-Go is a newly developed insulin delivery system. The push of a button inserts a needle into the patient once daily and remains attached for 24 hours. The V-Go is designed to release a set basal rate throughout the day, while allowing patients to provide up to 36 units of on-demand bolus insulin with the manual click of 2 buttons. It is a spring-loaded device filled daily with rapid-acting insulin that runs without the use of batteries or computer software. The main objective of this prospective active comparator study was to observe the A1C lowering effects of multiple daily insulin injections (MDII) versus the use of the V-Go insulin delivery system for patients with uncontrolled type 2 diabetes mellitus over a 3-month period. In addition, the effect on insulin requirement for these patients was assessed with secondary comparisons of weight, blood pressure, prevalence of hypoglycemic events, and quality of life before and after 3 months of intensified insulin therapy with regular monitoring by a clinical pharmacist at an internal medicine clinic. The average A1C lowering experienced by the 3 patients in the V-Go group was 1.5%, while the average A1C change in the 3 patients in the MDII group was an increase of 0.2%. All patients in the V-Go group experienced a decrease in insulin total daily dose (TDD), with an average decrease of 26.3 units. All patients in the MDII group experienced an increase in insulin TDD with an average of 15 units daily to achieve therapeutic goals individualized for each patient. All patients who underwent intensification of insulin therapy experienced an increase in subjective quality of life (QOL) as determined using the Diabetes-39 (D-39) questionnaire, though QOL results lacked statistical significance.

Use of communication tool within electronic medical record to improve primary nonadherence

OBJECTIVES The primary objective of this study was to determine if an online reminder decreased the rate of primary nonadherence for antihypertensive medications in patients seen in 2 primary care clinics in Omaha, NE. The secondary objectives were to determine if patients receiving the intervention achieved lower blood pressure values at follow-up visits and to determine if the intervention decreased the number of days between prescribing and prescription pick-up. METHODS A report was generated in an electronic health record to identify patients prescribed a new antihypertensive medication from a physician at one of the primary care clinics. Patients that failed to pick up this new prescription from the pharmacy within 7 days were sent an electronic reminder via an online patient portal. A baseline comparator group was created with the use of retrospective chart reviews for the 6 months before prospective data collection. Primary nonadherence rate and blood pressure values at follow-up visits were compared between the prospective and baseline comparator groups. RESULTS The primary nonadherence rate decreased from 65.5% to 22.2% when comparing the baseline and prospective groups, respectively. The mean days to prescription pick-up decreased from 24.5 to 12.56 in the baseline and prospective groups. The prospective group showed a larger decrease in systolic blood pressure (17.33 mm Hg vs. 0.75 mm Hg) and diastolic blood pressure (6.56 mm Hg vs. 2.25 mm Hg) compared with the baseline group. CONCLUSION An online reminder through the electronic medical record appears to improve patient primary nonadherence, number of days between prescribing and prescription pick-up, and blood pressure measurements at follow-up visits. This research shows that an online reminder may be a valuable tool to improve patient primary adherence and health outcomes. Further research is needed with the use of a larger sample population to support any hypotheses about the effectiveness of the intervention.

Euglycemic Diabetic Ketoacidosis Associated With Sodium–Glucose Cotransporter Type 2 Inhibitors in Patients With Type 2 Diabetes Mellitus Receiving Oral Therapy

Introduction and Objective: Postmarketing reports and warnings of serious adverse events such as diabetic ketoacidosis (DKA) have raised concern regarding the safety of sodium–glucose cotransporter 2 inhibitors (SGLT2i). This report describes 2 cases of symptomatic SGLT2i-associated euglycemic DKA (euDKA) leading to hospitalization in patients with type 2 diabetes mellitus (DM) previously well controlled on oral medications. Case Reports: Subject 1 is a 55-year-old female admitted with euDKA precipitated by infection and managed with intravenous insulin. This case was notable for a delayed diagnosis of euDKA and lack of clinical improvement despite withholding dapagliflozin. Subject 2 is a 62-year-old male admitted with euDKA precipitated by infection. His clinical condition improved rapidly and euDKA responded to withdrawal of empagliflozin alone. Discussion: Applying the Naranjo adverse medication reaction probability scale to each case (subject 1 score = 3 points; subject 2 score = 4 points) suggests these are possible adverse reactions to SGLT2i. Data from randomized controlled trials suggest DKA events in adults with type 2 DM receiving SGLT2i are rare and similar to placebo. However, data from a large cohort suggest these events occur more frequently and are associated with a 2-fold increased risk of DKA. Conclusion: This class of medications may be associated with a higher real-world risk of DKA in adults with type 2 DM than previously reported. Patients prescribed these medications should receive vigilant assessment for features of traditional DKA as well as euDKA.

Cost-Effectiveness of Glycemic Control

Diabetes mellitus affects approximately 24 million people in America. Analysis of the economic cost of diabetes in the USA are an estimated

Treatment of Parkinson’s disease psychosis

174 billion. Type 2 diabetes results from numerous causes and most highly associated causative factors being lifestyle choices. Dietary and exercise practices can increase or decrease one’s chance of developing type 2 diabetes. The cornerstones of preventing and treating type 2 diabetes, lifestyle modification and medication therapy, are aimed at maintaining optimal blood glucose levels. There is clear evidence of benefit that tight glycemic control decreases diabetes related complications and costs. Lifestyle modification is considered first line therapy for treatment and prevention of type 2 diabetes. The progressive nature of diabetes often requires the use of drug therapy to achieve glycemic targets. Tight glycemic control provides a cost effective means of reducing unnecessary health care expenses. Identifying ways to contain health care costs and obtain high value for our health care investments continues to be a priority.