Poster - 2014 American College of Clinical Pharmacy Annual Meeting

My poster for the 2014 American College of Clinical Pharmacy Annual Meeting

My abstract for the 2014 American College of Clinical Pharmacy Annual Meeting

Systematic Literature Review of Randomized Controlled Trials to Evaluate the Efficacy of Medical Marijuana for Analgesia

Shiny Parsai, M.S., Pharm.D. Candidate, Ronald A. Herman, Ph.D.; The University of Iowa College of Pharmacy, Sarah J. Johnson, Pharm.D., BCPS-AQ ID; The University of Iowa Healthcare

Purpose: Medical marijuana has had an evolving and controversial role for the treatment of pain.  This review summarizes and evaluates the current evidence from randomized controlled trials to examine the efficacy of medical marijuana as an analgesic. Methods: A systematic literature review was conducted using PubMed, IDIS, IPA, and CINAHL databases.  Articles were included if analgesia was a measured outcome in humans, the intervention involved tetrahydrocannabinol (THC) or derivative, was a randomized controlled trial, and was in English. Two authors did an initial screen of the abstracts to eliminate irrelevant articles and then a detailed review of the full text to identify the articles to be included in the evidence tables.  The third author reconciled differences if there was not a consensus. Data extraction included author name, date, type of pain, sample size, study design, intervention, efficacy, and adverse effects.  Evidence was organized and analyzed in separate evidence tables by type of intervention: inhaled cannabis, oral cannabis extracts, dronabinol, THC+CBD spray, and synthetic analogs. Results:  The initial literature search produced 133 unique articles.  Systematic review of abstracts, yielded 66 for full text review and 67 were excluded.   Full text review resulted in 48 articles to be included in the evidence tables. Conclusions:  Across each intervention type at least half of the studies showed a reduction in pain scores when compared to placebo.  There were 11 of 48 studies that indicated no difference from placebo for analgesia, with at least one study in each intervention type. There were 6 studies that compared the THC compound to another analgesic. It was not different from ibuprofen in one study, diphenhydramine in another study, and it was equivalent to codeine in two studies.  It was inferior to dihydrocodeine and to morphine in separate studies.  Adverse events were a concern in some of the studies.

Abstract - 2013 Obesity Society Annual Meeting

My abstract for the 2013 Obesity Society Annual Meeting

Subjective and Objective Methods to Examine Sleep Amount in Free-Living Families

Shiny Parsai, Randal Foster, Lorraine M. Lanningham-Foster Ames, IA

Background: Obesity and sleep insufficiency appear to be linked, possibly due to excess energy intake during wake time contributing to weight gain. To better understand the relationship between insufficient sleep and obesity, we need accurate and practical tools to quantify sleep. The purpose of this study was to compare two objective tools and one subjective tool to study sleep in free-living families. Methods: The study included 18 families (10 men, 17 women, 11 boys, and 5 girls). Subjects participated in a week-long study to monitor their sleep using an accelerometer (MSR145), a pattern-recognition system (SenseWear WMS® Mini armband), and sleep logs. BMI was calculated using height and weight and body composition was measured using air displacement plethysmography (BOD POD®). The objective tools were compared to the sleep log using regression analyses. Post-hoc tests were used with ANOVA and ANCOVA with a Bonferroni correction applied to give an overall significance level of P < 0.05. Results: The objective tools estimated similar sleep duration data from the subjects when compared with the sleep log. The accelerometer had a better correlation than the pattern recognition system when compared with the sleep log (0.399 vs. 0.1785, respectively).  Sleep duration was inversely correlated with age for all measurement tools. Conclusions: Future additional studies targeting free-living families to study sleep amount and obesity using these objective tools would be beneficial. It is also possible that the relationship between sleep duration and obesity may be explored in existing data sets where these objective measurement tools have been employed for other purposes such as physical activity assessment.

Awards - Diversity Stimulus Award and APhA-ASP/IPSF Leadership Position 2013-2014

University of Iowa College of Pharmacy
Diversity Stimulus Award

Proud to say that the APhA Medical Spanish Program was recently recognized for the Diversity Stimulus Award award!  Criteria for the award: Designed to honor individuals, programs, divisions and student organizations engaged in diversity initiatives which promote the development of an inclusive, diverse community.

APhA-ASP/IPSF Leadership Position 2013-2014

In the past years, the IPSF chapter at the University of Iowa College of pharmacy organized one event per semester.  We significantly changed that this year by implementing several innovative programs to educate student pharmacists about topics in international health.  The United States is a global melting pot, but it is important to appreciate that there is still a wide variety of cultural segments which speak their own languages and have their own cultural sensitivities when it comes to healthcare.  After seeing the difficulties that can result due to cultural differences and language barriers, we have made it a priority to increase opportunities for student pharmacists focusing on foreign languages and international issues.  We are excited to be a part of the pharmacy profession, to continue to learn and be involved in global health efforts.  We especially look forward to becoming pharmacists and being an essential part of the healthcare system so we can directly address issues of diversity and disparities in healthcare.  

Our goals and objectives for IPSF this year included the following:

·         Educate student pharmacists on pharmacy and health care issues around the globe

·         Promote the pharmacy profession in the community

·         Increase Spanish proficiency and cultural competency among student pharmacists

·         Promote inter-professional collaboration with other health care students and non-health care students

·         Provide opportunities for community service and involvement

·         Foster relationships with faculty and staff

·         Develop promotional materials for APhA-ASP/ IPSF

We began the year by educating student pharmacists about Pharmacy in the United Kingdom.  Pharmacist Sara Salem was originally licensed and practiced in hospital and community pharmacies in the United Kingdom.  She presented on her pharmacy experience in the UK and pharmacy education in the United Kingdom.  She provided information on the regulatory body, The General Pharmaceutical Council and the professional body, The Royal Pharmaceutical Society of Great Britain.  Student pharmacists learned about the National Health Service in the United Kingdom and global career opportunities in pharmacy.

During the month of October, American Pharmacists Month KRUI Radio Spot was developed to promote  pharmacy to the community.  The spot included the following information: Did you know that October is American Pharmacists Month?  At the University of Iowa College of Pharmacy we want to celebrate by letting you know that pharmacists are medication experts and your most accessible health care provider.  Stop by your local pharmacy today to learn about how your pharmacist can provide a range of services from medication counseling to selecting over-the-counter medications, and giving immunizations.  This October take the time to “Know Your Pharmacist, Know Your Medicine.”  This was a message from student pharmacists at the University of Iowa College of Pharmacy.

To prepare for APhA-ASP Mid Year Regional Meeting, we developed APhA-ASP Promotional Materials, which included thank you cards with the APhA-ASP logo to thank all the donors, speakers, and preceptors for all APhA-ASP events.  During our November meeting, we took 10 minutes to advertise the IPSF Student Exchange Program and the opportunity to learn about pharmacy around the globe. 

We spent over six months developing the Medical Spanish Pilot Program, for student pharmacists.  Developing the program involved surveying students, finding a professor, fostering support from faculty and students, and appropriating funding.   The six week workshop began in January and met two hours per week during the evening.  We had originally planned to only have one group of 15 students but due to demand, added a second group of 15 students.  After gaining approval from faculty, students were able to submit the cost of the Medical Spanish fee to the College of Pharmacy for reimbursement.  The college provided $1800 in reimbursements for students to enroll in the workshop.  With the increasing Spanish speaking population both in Iowa and the US, the goal of the program is to prepare student pharmacists to communicate effectively with Spanish speaking patients.  Through this workshop, the students not only learn the language, but also cultural differences that impact a patients' care.  At the conclusion of the six week program, a Mock Medical Spanish Clinic, was organized for student pharmacists to practice their newly gained skills with fluent Spanish speakers.  We developed patient cases and the students worked to assess the patient’s ailments and recommend an appropriate medication in Spanish. 

We worked with Proteus to organize a Long Sleeve Shirt Drive for Farm Workers Awareness Week for migrant farm workers in Iowa. We collected 30 shirts that were donated to migrant farm workers this summer during their pesticide training.  For World Tuberculosis Day we arranged for a video screening of Exposed: The Race Against Tuberculosis and a presentation by Andy Weigel, Disease Prevention Specialist for Johnson County Public Health, focusing on infectious disease control and prevention.

We applied for and were awarded the Paul Ambrose Grant through the Association for Prevention and Teaching. The $350 grant assisted with Proteus Migrant Farm Workers Mobile Clinics.  The grant provides support for medication boxes, medication list pocket cards, and educational materials related to medication adherence to the mobile health clinic site in Williamsburg, IA during Summer 2014.  Student pharmacists have signed up to help at 6 summer clinics to serve a total of 300 migrant farmworkers.   Prior to the summer mobile clinics, we organized a Proteus Medication Packaging Service Event during which student pharmacists spent a full day dispensing medications for the summer clinics. 

For World Malaria Day Fundraising Event we had a yogurt parfait breakfast bar sale to raise money for the UNICEF Nothing But Nets charity to provide malaria nets in developing countries.  We collaborated with Students for Interprofessional Education to organize a campus wide Interdisciplinary Book and Food Drive that raised over 700 books and 150 items of food.  The books were donated to World Wide Books and the food was donated to Proteus migrant farm workers food pantry.

All events and efforts were new this year and have had a significant impact on both student pharmacists and the community.  

Drug Information - Statins in patients with ESRD

Question: Hyperlipidemia

Statins are often prescribed for both primary and secondary prevention of cardiovascular disease. Patients with end-stage renal disease (ESRD-dialysis) are at significantly increased risk for cardiovascular disease and are often prescribed statins. What is the evidence to support or refute using statins in patients with ESRD?

Answer

Patients with end-stage renal disease are at significantly increased risk for cardiovascular disease than the general population¹.  Since statins have shown to reduce cardiovascular events in patients at high cardiovascular risk, it is important to consider the evidence of statin therapy in patients with end stage renal disease². The 4-D and AURORA trials have studied the use of statins in patients with end-stage renal disease

The 4-D study by Wanner and colleagues, was a multicenter, randomized, double-blind, prospective study of 1255 subjects with type 2 diabetes mellitus receiving maintenance hemodialysis.   Patients from ages 18 to 80 years of age were randomly assigned to atorvastatin 20 mg/day or placebo.  Adherence rates of around 80% were similar in both study groups.  The primary end point included death from cardiac causes, nonfatal myocardial infarction, and stroke.  After four weeks of treatment, the atorvastatin group had a 42 percent decrease in low density lipoprotein (LDL) cholesterol compared to the placebo group that had a 1.3 percent reduction.  Though atorvastatin decreased the rate of all cardiac events combined (relative risk 0.82; 95 percent confidence interval 0.68 to 0.99; P = 0.03), it did not affect total mortality (relative risk, 1.12; 95 percent confidence interval, 0.81 to 1.55; P=0.49).  Overall, atorvastatin did not significantly affect the primary end point that included cardiovascular death, nonfatal myocardial infarction, and stroke in diabetic patients who received atorvastatin at the median follow up period of four years³.  The study had very low rates of adverse drug reactions, with no rhabdomylysis or severe liver disease in either group.  The Aurora trial consisted of 2776 hemodialysis patients in a multicenter, randomized, double-blind, prospective trial.  Patients from ages 50 to 80 were randomly assigned to rosuvastatin 10mg/day or placebo.  The combined primary end point was death from cardiovascular causes, nonfatal myocardial infarction, or nonfatal stroke.  At three months, the rosuvastatin group had lowered LDL by 43% (100 to 58 mg/dL) compared to no change with placebo (99 to 98 mg/dL).  At a median follow-up period of 3.8 years, the reduction in LDL cholesterol level did not have a significant effect on the composite primary end point of death from cardiovascular causes, nonfatal myocardial infarction, or nonfatal stroke.  Increased incidence of adverse events was not associated with rosuvastatin therapy⁴.  Results of a 2013 meta-analysis by Nemerovski et al included clinical trials evaluating cardiovascular end points of statins in patients with End Stage Renal Disease (ESRD).  The meta-analysis reported that “statin therapy has failed to significantly alter the course of cardiovascular disease events in patients with ESRD.⁵”

Conclusion

Although atorvastatin in the 4-D study and rosuvastatin in the Aurora trial significantly lowered the levels of LDL cholesterol in dialysis patients, statins overall did not significantly affect the primary end point in both studies that included cardiovascular death^3,4.  Even though statins were well tolerated, they have failed to significantly affect cardiovascular disease in patients with end stage renal disease and should not be recommended.

Author: Shiny Parsai, Pharm.D. Candidate 2016

Date: May 9, 2014

References

1.      Foley RN, Parfrey PS, Sarnak MJ. Clinical epidemiology of cardiovascular disease in chronic renal disease. Am J Kidney Dis. 1998 Nov;32:Suppl 3:S112-S119.

2.      Baigent C, Keech A, Kearney PM, et al. Efficacy and safety of cholesterol-lowering treatment: prospective meta-analysis of data from 90,056 participants in 14 randomised trials of statins. Lancet. 2005 Sept 27;366:1267–1278. 

3.  Wanner C, Krane V, Marz W, et al. Atorvastatin in patients with type 2 diabetes mellitus undergoing hemodialysis. N Engl J Med. 2005 July 21;353:238–248.

4.     Fellstrom BC, Jardine AG, Schmieder RE, et al. Rosuvastatin and cardiovascular events in patients undergoing hemodialysis. N Engl J Med. 2009 April 2;360:1395–1407.

5.     Nemerovski CW, Lekura J, Cefaretti M, et al. Safety and Efficacy of Statins in Patients with End-Stage Renal Disease. Ann Pharmacother. 2013 July 18; 47(10) 1321–1329.

Conferences & Meetings - Opiod use and abuse deterrent strategies

Special Event

Cold Night/Hot Topic – Opiod use and abuse deterrent strategies – 1/24/2014

Last night I attended a special event put together by professors at the University of Iowa College of Pharmacy. The event speakers discussed various aspects of opiod abuse.  We had a pharmacist discuss his experience in using opiods in pain management and using pain contracts as a way to prevent abuse. There were also speakers from the Iowa Prescription Monitoring Program, a lieutenant from the Johnson County Sheriffs office, a compounding pharmacist, and a lawyer from a Mallinckrodt Pharmaceuticals.  Currently, there are challenges to developing a national prescription monitoring database so the PMP is working to develop a program with bordering states and then hopefully expand to other states. The compounding pharmacist spoke about how he does not accept insurance but rather patients pay him directly and then the patients can submit the claim to their insurance company.  He is able to do this by establishing his compounding business as a separate corporation. The lawyer was very interesting as he discussed opiod use from a manufacturers perspective and all the efforts their company is involved in to reduce drug abuse. One such effort is creating dummy medications with no active pharmaceutical ingredient and loaning them to law enforcement for drug busts. I am glad to see that even manufacturers are thinking about this issue and I really enjoyed hearing from all the other speakers.