Am J Health Syst Pharm
· 2026 May · PMID 42087298
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PURPOSE: Sickle cell disease (SCD) is marked by recurrent vaso-occlusive crises (VOCs) that often require opioid analgesia. However, national opioid stewardship efforts may inadvertently affect pain management access for...PURPOSE: Sickle cell disease (SCD) is marked by recurrent vaso-occlusive crises (VOCs) that often require opioid analgesia. However, national opioid stewardship efforts may inadvertently affect pain management access for individuals with high disease burden, such as those experiencing multiple VOCs annually. The objective was to characterize temporal and agent-specific opioid prescribing patterns in patients with severe SCD, defined as experiencing 3 or more VOCs within a 12-month period. SUMMARY: This retrospective cohort study used integrated electronic health record data (2014-2023) from the University of Pittsburgh Medical Center, a comprehensive SCD center. Adults (≥18 years) with 3 or more qualifying VOCs within a rolling 12-month period were identified. The primary outcome was receipt of an opioid within 7 days of the third VOC. We examined annual trends in opioid use per 100 VOCs and used mixed-effects logistic regression to assess the association between calendar year and post-VOC opioid use, adjusting for patient characteristics. The cohort included 325 patients contributing 1,179 qualifying VOC periods. Overall opioid prescribing declined over time (odds ratio, 0.92 per year; 95% CI, 0.89-0.96). Oxycodone showed the most consistent reduction, while trends for morphine, fentanyl, and hydromorphone varied. Despite high clinical need, the probability of receiving opioids after a VOC episode decreased steadily over the study period. CONCLUSION: In patients with severe SCD, opioid prescribing declined significantly between 2014 and 2023. These findings highlight the need for nuanced, individualized stewardship strategies that preserve access to effective pain control while addressing broader efforts to reduce inappropriate opioid use.
Zimmerman DE, Goodstein D, Durney PA
… +2 more, Patel-Francis SH, London KS
Am J Health Syst Pharm
· 2026 May · PMID 42087295
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PURPOSE: Medetomidine, a potent α2-adrenergic agonist, is an emerging contaminant in the US illicit opioid supply. It is a racemic mixture that includes the sedative dexmedetomidine and can lead to severe and complicated...PURPOSE: Medetomidine, a potent α2-adrenergic agonist, is an emerging contaminant in the US illicit opioid supply. It is a racemic mixture that includes the sedative dexmedetomidine and can lead to severe and complicated withdrawal symptoms requiring novel management strategies. In this therapy update, we provide insights on the identification and management of medetomidine withdrawal based on our clinical experiences with it over the past year. SUMMARY: Medetomidine withdrawal can occur precipitously, typically 4 to 6 hours after last use in regular users, and lead to severe symptoms and complications including agitation, tremors, and widespread sympathetic activation. Prompt identification of withdrawal is vital to initiate oral and transdermal α2-agonist therapy, often at doses higher than those required for labeled indications. Severe nausea and vomiting are typically present and may be refractory to standard treatments and prevent oral therapies from being administered. Intravenous dexmedetomidine is recommended for those for whom oral α2-agonist therapy is ineffective or who are unable to tolerate enteral therapies. This may require aggressive dose titration and infusion rates that are above those in typical sedation protocols. In addition to α2 withdrawal, patients may have withdrawal from concomitant opioids, benzodiazepines, or other substances that requires additional treatment. CONCLUSION: Medetomidine withdrawal can lead to severe hemodynamic and autonomic complications that require a multimodal treatment strategy. Clinicians should be familiar with the signs, symptoms, and timing of medetomidine withdrawal along with the complex management that is required.
Arnold OJ, Stettner S, Ippoliti C
… +2 more, Russell T, Dupart P
Am J Health Syst Pharm
· 2026 May · PMID 42087292
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PURPOSE: This report evaluates the structure, impact, and resource demands of a Proactive Drug Shortage Committee (PDSC) within a large, multicenter health system, highlighting its response to the 2024 intravenous fluid...PURPOSE: This report evaluates the structure, impact, and resource demands of a Proactive Drug Shortage Committee (PDSC) within a large, multicenter health system, highlighting its response to the 2024 intravenous fluid (IVF) shortage and associated financial and labor burdens. SUMMARY: The PDSC model described is implemented across an 11-hospital health system and consists of pharmacy leaders, buyers, informatics specialists, and clinical and operational staff. Meeting weekly, the committee monitors shortages utilizing real-time data to influence mitigation strategies rooted in coordination, collaboration, and communication. The 2024 natural disaster Hurricane Helene resulted in a widespread IVF shortage during which the PDSC implemented conservation protocols, electronic health record alerts, clinical restrictions, and internal compounding. These efforts led to a 33% reduction of IVF usage within 25 days of the event. Time assessments revealed significant increases in shortage-related FTE requirements during crisis periods, with roles such as clinical pharmacists and data analysts experiencing up to 400% increases. Financially, the health system shifted from 8.45% under budget in September 2024 to 8.55% over budget during the peak shortage months due to overtime, compounding resources, and alternative sourcing. CONCLUSION: A PSDC is an integral part of a health system, with the model demonstrated to be effective in enabling a scalable, multidisciplinary approach to successfully managing drug shortages. Its proactive nature, use of real-time data, and cross-functional collaboration are essential to preserving patient care and operational continuity. Crisis-level shortages demand heightened labor and financial investment, reinforcing the need for dedicated, system-wide preparedness and response mechanisms.
McNicol M, Wise K, El-Barrad S
… +4 more, Oberle E, Taxter A, Abdel-Rasoul M, Maltz RM
Am J Health Syst Pharm
· 2026 May · PMID 42084356
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PURPOSE: The expiration of market exclusivity for Humira (adalimumab) in February 2023 led to the introduction of 10 biosimilars, raising questions about their impact on prescribing trends, payer responses, and formulary...PURPOSE: The expiration of market exclusivity for Humira (adalimumab) in February 2023 led to the introduction of 10 biosimilars, raising questions about their impact on prescribing trends, payer responses, and formulary management in pediatrics. The primary objective of this study was to compare time to prior authorization approval between adalimumab biosimilars and the originator product during the first 2.5 years following biosimilar market entry. Secondary objectives were to describe the reason for switching adalimumab products in those already established on adalimumab therapy and to identify reported intolerances associated with biosimilar products. METHODS: To prepare for biosimilar launches, the clinical pharmacy team provided education to clinic staff and the health-system specialty pharmacy (HSSP), engaged with manufacturers to identify resources related to biosimilar products, and established prescribing workflows for patients on adalimumab. An observational study was then conducted from February 1, 2023, to June 30, 2025, across dermatology, gastroenterology, and rheumatology outpatient clinics of an integrated HSSP to assess biosimilar prescribing trends, time to authorization approval, and reason for switches. Included prescriptions were for patients naïve to adalimumab or switching between adalimumab products. RESULTS: Evaluation of 350 prescriptions for adalimumab-naïve patients found that Humira was the preferred product for 290 prescriptions (82.9%). In adalimumab-naïve patients, the median time to prior authorization approval was 4 days (interquartile range [IQR], 2-9 days), with no significant difference between Humira (4 days; IQR, 2-10 days) and biosimilars (3 days; IQR, 2-9 days; P = 0.39). Among 256 prescriptions for non-adalimumab-naïve patients, the majority (86%) were for switches from Humira to a biosimilar, primarily due to formulary preference (77%), new insurance for the patient (11.3%), or exhaustion of copay card funds (4.7%). CONCLUSION: Despite inherent complexities of biosimilar implementation, this study demonstrates that a coordinated, pharmacist-led approach supports timely access to therapy and minimizes treatment delays.
Am J Health Syst Pharm
· 2026 May · PMID 42084327
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PURPOSE: Amyloid transthyretin cardiomyopathy (ATTR-CM) treatment guidelines do not align in their recommendations of which patients should receive transthyretin stabilizers based on New York Heart Association (NYHA) cla...PURPOSE: Amyloid transthyretin cardiomyopathy (ATTR-CM) treatment guidelines do not align in their recommendations of which patients should receive transthyretin stabilizers based on New York Heart Association (NYHA) classification. We conducted a meta-analysis to assess the impact of transthyretin stabilizers on outcomes in patients with ATTR-CM in different NYHA classification subgroups. METHODS: We searched PubMed, the Cochrane Central Register of Controlled Trials, trial registers, and regulatory agency websites through July 2025 to identify randomized controlled trial data for transthyretin stabilizers reporting on all-cause mortality (ACM) and/or frequency of cardiovascular hospitalization (CVH) and 6-meter walk distance (6MWD) stratified by NYHA classification at baseline. We pooled effect estimates with 95% confidence intervals (CIs) using random-effects methods. RESULTS: We identified 2 RCTs with a total of 1,052 participants, of whom 77.2% had NYHA class I or II disease and the remainder had class III disease. In the NYHA class I/II subgroup, all outcomes showed benefit with treatment compared to placebo: greater effectiveness in reducing ACM or CVH frequency (win ratio, 1.79; 95% CI, 1.40-2.30), reduced hazard of ACM (hazard ratio, 0.64; 95% CI, 0.46-0.88) and rate ratio of CVH (rate ratio, 0.46; 95% CI, 0.38-0.57), and improved 6MWD (least-squares mean difference, 65.16; 95% CI, 25.85-104.48). In the NYHA class III subgroup, no differences were found for treatment vs placebo. CONCLUSION: Transthyretin stabilizers showed beneficial effects on all outcomes when assessed in patients with NYHA class I/II disease, but no benefit was found in the NYHA class III subgroup. These findings reinforce the importance of early-stage ATTR-CM diagnosis and treatment.
Am J Health Syst Pharm
· 2026 May · PMID 42083501
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PURPOSE: This study examined whether rural veterans with multisymptom chronic pain presentations, including those diagnosed with fibromyalgia, migraine, and/or irritable bowel syndrome (IBS), were at heightened risk for...PURPOSE: This study examined whether rural veterans with multisymptom chronic pain presentations, including those diagnosed with fibromyalgia, migraine, and/or irritable bowel syndrome (IBS), were at heightened risk for polypharmacy with central nervous system (CNS)-active medications, a potentially risky prescribing practice. METHODS: Administrative data were used to identify veterans receiving care for fibromyalgia, migraine, or IBS during 2022. Negative binomial regression models, conducted separately for fibromyalgia, migraine, and IBS, examined the impact of rural residence and rural site of care on number of concurrent CNS medications. Models were then adjusted for demographics and medical and psychiatric comorbidities. RESULTS: A total of 250,533 veterans were treated for fibromyalgia (n = 30,462), migraine (n = 188,640), and/or IBS (n = 49,169) in the Veterans Health Administration in 2022. Rates of polypharmacy were 16.2% for those with fibromyalgia, 13.5% for those with migraine, and 8.2% for those with IBS. In fibromyalgia, rural veterans' mean number of concurrent CNS-active medications was 2.59 (SD, 1.92), compared to 2.63 (SD, 1.90) for urban veterans; in migraine, the mean (SD) number of concurrent medications was 2.43 (1.87) in rural veterans, compared to 2.40 (1.83) in urban veterans; and in IBS, the mean (SD) number of concurrent medications was 1.75 (1.75) in rural veterans, compared to 1.79 (1.75) in urban veterans. In adjusted analyses, minimal differences were found between rural and urban-dwelling veterans in the risk of an increased number of concurrent CNS medications (adjusted incident rate ratios [aIRRs] ranged from 1.01 to 1.03) and between those receiving primary care from rural clinics versus medical centers (aIRRs ranged from 0.95 to 0.97). CONCLUSION: These findings do not support the hypothesis that rural veterans are at increased risk for CNS polypharmacy.
Am J Health Syst Pharm
· 2026 May · PMID 42083464
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PURPOSE: To quantify and evaluate Accreditation Council for Pharmacy Education (ACPE)-accredited continuing pharmacy education (CPE) activities related to medications subject to risk evaluation and mitigation strategies...PURPOSE: To quantify and evaluate Accreditation Council for Pharmacy Education (ACPE)-accredited continuing pharmacy education (CPE) activities related to medications subject to risk evaluation and mitigation strategies (REMS) requirements that were offered during the period 2014-2023. METHODS: This study was a retrospective analysis utilizing the ACPE CPE Provider Web Tool database to examine CPE activities designated as REMS-associated that were available between September 1, 2014, and December 31, 2023. CPE activity variables including provider type, joint providership, year, target audience, activity type, activity title, keywords, contact hours, number of participants, industry funding, and learning objectives were extracted and analyzed for each activity. Content analysis was used to identify categories of topics that were covered within these activities. RESULTS: A total of 160 activities met inclusion criteria after duplicate entries were removed, representing a small fraction (0.05%) of all ACPE-accredited activities offered during the selected time frame. The majority of available activities were knowledge-based (83.1%, n = 133) and delivered live (66.3%, n = 106). Colleges or schools of pharmacy were the most common provider type (20.6%, n = 33). Six thematic categories emerged from content analysis, with "law or regulatory focused" being most prevalent. CONCLUSION: REMS-related CPE opportunities were limited in both availability and scope. Expanding accessible, integrated, and innovative REMS education formats through CPE may enhance pharmacist competence and patient safety.
Tichy EM, Rim MH, Tadrous M
… +5 more, Schumock GT, Cuellar S, Johnson TJ, Newell MK, Hoffman JM
Am J Health Syst Pharm
· 2026 Apr · PMID 42059345
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PURPOSE: To report historical patterns of pharmaceutical expenditures, to identify factors that may influence future spending, and to predict growth in drug spending in 2026 in the United States, with a focus on the nonf...PURPOSE: To report historical patterns of pharmaceutical expenditures, to identify factors that may influence future spending, and to predict growth in drug spending in 2026 in the United States, with a focus on the nonfederal hospital and clinic sectors. METHODS: Historical patterns were assessed by examining data on drug purchases from manufacturers using the IQVIA National Sales Perspectives database. Factors that may influence drug spending in hospitals and clinics in 2026 were reviewed-including new drug approvals, patent expirations, and potential new policies or legislation. Focused analyses were conducted for biosimilars, cancer drugs, endocrine drugs, generics, specialty drugs, and vaccines. For nonfederal hospitals, clinics, and overall (all sectors), estimates for growth of pharmaceutical expenditures in 2026 were made based on a combination of quantitative analyses and expert opinion. RESULTS: In 2025, overall pharmaceutical expenditures in the US grew 12.7% compared to 2024, for a total of $915.2 billion. Utilization (a 9.3% increase) drove this increase, while growth due to new drugs (0.9%) and price increases (1.2%) had a modest impact. Tirzepatide was the new top drug in 2025, followed by semaglutide and apixiban. Drug expenditures were $42.9 billion (a 9.6% increase) and $190.5 billion (a 19.0% increase) in nonfederal hospitals and in clinics, respectively. In clinics, volume drove drug expense growth, contributing with a 13.6% increase, while price and new drugs each contributed with a 2.7% increase. In nonfederal hospitals, expenditure growth was driven by increases in volume (4.6%), new products (3.7%), and prices (1.5%). Several new drugs that will influence spending are expected to be approved in 2026. Specialty, endocrine, and cancer drugs will continue to drive expenditures. CONCLUSION: For 2026, we expect overall prescription drug spending to rise by 10.0% to 12.0%, whereas in clinics and hospitals we anticipate increases of 14.0%-16.0% and 4.0%-6.0%, respectively, compared to 2025. These national estimates of future pharmaceutical expenditure growth may not be representative of any health system because of the myriad of local factors that influence actual spending.
Am J Health Syst Pharm
· 2026 Apr · PMID 42054503
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PURPOSE: This study aimed to identify which traditional productivity metric-doses dispensed, medication charges, or patient days-most closely correlates with the workload of clinical pharmacists at UNC Hospitals Hillsbor...PURPOSE: This study aimed to identify which traditional productivity metric-doses dispensed, medication charges, or patient days-most closely correlates with the workload of clinical pharmacists at UNC Hospitals Hillsborough Campus. METHODS: A modified Delphi process was used to define the work of clinical pharmacists. Pharmacists identified their routine clinical responsibilities, and a final list of direct patient care activities was developed. These activities were quantified using data from fiscal year 2024. The total number of clinical activities was compared to the traditional productivity metrics using Pearson correlation coefficients. RESULTS: Among the traditional metrics, medication charges demonstrated the strongest correlation with the sum of clinical activities (r = 0.75, P < 0.001), followed by doses dispensed (r = 0.70, P < 0.001). When orders verified were removed from the sum of clinical activities, patient days had the strongest correlation (r = 0.76, P < 0.001). CONCLUSION: While no traditional metric fully captures the complexity of pharmacist clinical activities, medication charges may serve as the most practical surrogate under the current practice model at UNC Hillsborough.
Am J Health Syst Pharm
· 2026 Apr · PMID 42045138
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PURPOSE: To explore whether the vancomycin plus piperacillin/tazobactam (VPT) combination increased risk of acute kidney injury (AKI) compared to vancomycin plus cefepime (VC) in a cohort of Hispanic patients. METHODS: T...PURPOSE: To explore whether the vancomycin plus piperacillin/tazobactam (VPT) combination increased risk of acute kidney injury (AKI) compared to vancomycin plus cefepime (VC) in a cohort of Hispanic patients. METHODS: This was a single-center, retrospective study. Adult Hispanic patients receiving at least 48 hours of concomitant vancomycin and (-lactam therapy were included. Patients were excluded if they had documented allergies to study antibiotics, had antibiotics indicated for a central nervous system infection, were pregnant, had cystic fibrosis, a malignancy, or a creatinine clearance level of 30 mL/min or less, or had preexisting AKI within 48 hours before initiation of antibiotics. The primary outcome was the incidence of AKI, defined by a rise in serum creatinine level as described in KDIGO guidelines. A subgroup analysis was performed to assess AKI incidence with stratification into 3 vancomycin area under the curve (AUC) ranges: 400-499 mg · h/L, 500-599 mg · h/L, and ≥600 mg · h/L. RESULTS: A total of 89 patients were included in the study: 45 in the VPT group and 44 in the VC group. AKI occurred in 23 of the patients receiving VPT (51%) compared to 10 of the patients receiving VC (23%) (odds ratio [OR], 2.25; 95% confidence interval [CI], 1.22-4.16; P = 0.006). For the subgroup analysis, a significant difference was seen in AKI between VPT and VC in the subgroup with a vancomycin AUC of 400-499 mg · h/L (OR, 0.303; 95% CI, 0.102-0.897; P = 0.035). CONCLUSION: This study suggests that there might be higher risk of AKI with VPT in the Hispanic population. Further studies are needed to confirm these findings and to investigate potential ethnicity-specific susceptibility to kidney injury associated with vancomycin combination therapy.
Am J Health Syst Pharm
· 2026 Apr · PMID 42041092
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PURPOSE: Hospital readmissions are a measure of the quality of postdischarge outpatient care. A review of the research literature revealed a lack of published multicenter studies evaluating hospital readmission rates and...PURPOSE: Hospital readmissions are a measure of the quality of postdischarge outpatient care. A review of the research literature revealed a lack of published multicenter studies evaluating hospital readmission rates and the timing of readmission events within the first 30 days after discharge among patients receiving home parenteral nutrition (HPN). Thus, the objective of this research was to evaluate hospital readmissions in patients newly discharged on HPN and to determine the 30-day hospital readmission rate, the mean number of days to hospital readmission, the day of the week of hospital discharge on HPN for readmissions, and the cause of readmission. METHODS: This descriptive and retrospective multicenter study used 30-day hospital readmission data that were submitted to the National Home Infusion Foundation's benchmarking program by home infusion providers. RESULTS: Data were collected on 1,692 patients on HPN from 21 home infusion provider locations. The 30-day readmission rate was 36.8% (n = 623). When the days to hospital readmission were categorized into 2 groups, 0-14 and 15-30 days, 66.7% of readmitted patients were in the first of these categories. Reasons for readmission included vascular access device infection (57.8%), insufficient response to HPN (28.4%), and vascular access device-related events other than infection (9.5%). CONCLUSION: This study demonstrated that HPN-related hospital readmissions are more likely to occur in the first 14 days at home. Earlier readmissions highlight the importance of the transition care process, specifically addressing readiness for discharge home, and closer monitoring and follow-up by the home infusion team. Understanding the risk timeframe for readmission will help providers assess their current follow-up practices.
Linville S, Metzger A, Etemady-Deylamy A
… +2 more, Patri M, Rondeau H
Am J Health Syst Pharm
· 2026 Apr · PMID 42033754
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PURPOSE: Approximately 10% of US patients report a penicillin allergy, yet fewer than 1% have a true immunoglobulin E-mediated reaction. Mislabeled allergies contribute to unnecessary use of broad-spectrum antibiotics, i...PURPOSE: Approximately 10% of US patients report a penicillin allergy, yet fewer than 1% have a true immunoglobulin E-mediated reaction. Mislabeled allergies contribute to unnecessary use of broad-spectrum antibiotics, increasing healthcare costs, hospital stays, antimicrobial resistance, and mortality. Despite guideline recommendations for risk stratification and allergy delabeling, implementation remains limited. PEN-FAST is a validated clinical tool used to facilitate delabeling without resource-intensive skin testing. This study aimed to determine the prevalence of low-risk penicillin allergy among adult patients using the PEN-FAST tool within a pharmacist-led medication reconciliation process. METHODS: A multicenter, retrospective prevalence study was conducted at 2 community hospitals. Patients admitted or seen in the emergency department from September 16 through December 16, 2024, with a documented penicillin allergy who underwent a pharmacist-performed PEN-FAST assessment were included. The primary outcome was the proportion of patients classified as having low-risk penicillin allergy (PEN-FAST score of <3). Secondary outcomes included allergy delabeling rates and the frequency of direct oral penicillin challenges. Descriptive analysis was used to evaluate the results. RESULTS: Of 95 patients assessed, 74% (n = 70) were classified as low risk. Among these low-risk patients, 10% (n = 7) had their allergy label removed and 3% (n = 2) underwent a direct oral penicillin challenge, with both tolerating penicillin without adverse reactions. CONCLUSION: These findings suggest that pharmacist-led PEN-FAST implementation is a feasible strategy to identify low-risk penicillin allergies, but allergy delabeling and oral challenge rates remain low. Further efforts are needed to integrate PEN-FAST into clinical workflows and enhance antimicrobial stewardship.