Scientific Posters

2021 NCAP Scientific Posters

Title: Identifying barriers to utilization of a medication access program among referred patients surveyed after discharge from an acute care hospital Authors: Paige E. Greene, T. Wells, A. Wright, J. Wood, J. McLellan, R. Bowers, J. Angell, E. Hudson, M. Pitt

Background/Purpose: For uninsured residents of select counties in North Carolina, the Cumberland County Medication Access Program (CCMAP) provides prescriptions at no cost. Uninsured patients hospitalized at Cape Fear Valley Medical Center are referred to CCMAP at discharge by Cape Fear Valley Health System employees, primarily Coordination of Care personnel and Outpatient Pharmacy personnel. The purpose of this study is to describe the most frequently reported utilization barriers among surveyed patients referred to CCMAP following discharge from Cape Fear Valley Medical Center. Methods: This is a single-center, survey-based, descriptive research study. Referring Cape Fear Valley Health System employees collected the Medical Record Number (MRN) of patients referred to CCMAP at discharge between 10/22/2020 and 12/31/2020. These patients were contacted by a research team member via telephone at least 30 days after discharge to voluntarily participate in a survey regarding their ability to receive prescriptions from CCMAP after discharge. Patient reported utilization barriers and demographics were recorded. A similar survey was voluntarily completed by referring Health System employees. Employee reported utilization barriers were collected to identify discrepancies in perceived utilization barriers among discharged patients and referring Health System employees. Results: There were 69 patients referred to CCMAP at discharge by Outpatient Pharmacy personnel. A total of 17 patients met inclusion criteria and completed the survey. Of these, 35.29% of patients reported their greatest utilization barrier to be uncertainty about how to apply for CCMAP. Additionally, 25 surveys were completed by referring Outpatient Pharmacy personnel. Of these, 56% of participants reported they believe the greatest utilization barrier to be patient uncertainty about how to apply for CCMAP. Conclusions: Uninsured patients discharged from Cape Fear Valley Medical Center could benefit from increased assistance with completing CCMAP applications and enrollment with the program prior to discharge in order to improve continuity of care. Title: Benefits of utilizing pharmacy learners in an inpatient anticoagulation education service Authors: Carrie Baker, PharmD, MBA, BCPS; Emily Ghassemi, PharmD, MSCR, BCACP, CDE, CPP; Riley Bowers, PharmD, BCCP, BCPS

Institution: Cape Fear Valley Medical Center, Fayetteville, NC; Campbell University College of Pharmacy & Health Sciences, Buies Creek, NC Objective. The 2019 Hospital National Patient Safety Goal 03.05.01 indicates education regarding anticoagulant therapy should be provided to patients and families. Previous studies assessing pharmacist and pharmacy learner involvement in oral anticoagulation (OAC) education services have focused on patient-related outcomes, with limited emphasis on the additional benefit to the learner. The purpose of this study was to assess the benefit of pharmacy learner involvement in anticoagulation education services both clinically and through their perceptions of participating in the service.

Methods. This prospective cohort study utilized assessments of both learners’ knowledge and perceptions of providing OAC education before and after a 1-month learning experience, where students provided counseling 2-3 days per

week. The primary endpoint was comparing each learners’ pre and post OAC education knowledge assessments. Secondary endpoints included perceived benefit of learner participation in the service, percentage of patients able to recall the counseling session and information provided, and number of interventions made related to inappropriate OAC therapy. Results. A total of 35 pharmacy learners were included in this study with 277 patients receiving counseling, and 40 interventions made related to inappropriate therapy from June 2020 through March 2021. The mean pharmacy learner score improved significantly (21.52%) between pre-assessment and post-assessment, 48.67% vs. 70.19% respectively (95% CI 0.178 to 0.252, p<0.0001). Pharmacy learners also indicated a statistically significant change in perceptions related to their patient counseling abilities. Additionally, 124 patients who received counseling were able to be contacted following hospitalization, 90.32% were able to recall the medication and indication, and 87.9% found the counseling useful. Conclusion. Pharmacy learner participation within anticoagulation education services significantly improved learner knowledge and confidence in their counseling abilities. It also allowed for over 70% of patients to successfully recall pertinent information about their anticoagulants over a week later and improved patient care through dosing interventions.

Title: Cost Analysis of Direct Oral Anticoagulant Rivaroxaban versus Enoxaparin for Prophylaxis of Venous Thromboembolism in Acute Medically Ill Patients Authors: Phoenix Riley (PharmD, MSc Candidate), Meredith Lilley (MSc, DHSc Candidate), Faculty Advisor: Dr. Charles Carter, PharmD, MBA Objectives: Acute medically ill patients are at high risk for venous thromboembolism (VTE). Subcutaneous enoxaparin is the ‘gold’ standard therapy in these patients. Recently, one direct oral anticoagulant has been approved for this indication by the FDA; rivaroxaban (2019). The aim of this study was to perform a cost analysis of rivaroxaban versus enoxaparin for VTE prophylaxis. Methods: Cost estimates of rivaroxaban and enoxaparin were obtained from publicly available sources (CMMS, Drugs.com). Cost estimates for clinical outcomes were garnered from literature and public databases (CMMS). Data from a key trial (rivaroxaban: MAGELLAN) was utilized to determine probabilities of potential clinical outcomes. A decision tree model was constructed (TreeagePro®) for analysis of the therapy relative to enoxaparin. Doses/ regimens were consistent with approved labeling. Costs were reported in 2019 United States currency (USD) and the study was performed from a societal perspective. Discount rate was 5%. Monte Carlo (probabilistic sensitivity) analyses was performed. Results are expressed as expected value (EV) or the average cost for each treatment strategy. Two-way sensitivity analyses using 50% to 200% of the key VTE clinical outcomes was performed. Results: The EV for the comparison of enoxaparin to rivaroxaban favored enoxaparin ($1,271 versus $1,650; 22.3% difference). Conclusions: In acute medically ill hospitalized patients at risk for VTE, the EV of enoxaparin was more optimal than rivaroxaban based upon clinical trial results. These results are valuable in guiding effective clinical decision making and assessments for formulary inclusion. As further clinical outcome data becomes available, it is recommended that similar analyses be repeated to better model real-world settings.

Title: Acute liver injury following exposure to sulfamethoxazole/ trimethoprim

Authors: Sarah Wise, PharmD/ MSCR Candidate Class of 2022, Rebekah Sowers, PharmD/MSCR Candidate Class of 2022, Avishek Nagi, Statistical Advisor, Dr. Melissa Holland, PharmD, MSCR, Dr. Ayako Suzuki, MD, PhD Institution: Campbell University College of Pharmacy & Health Sciences, Buies Creek, NC, Department of Medicine, Durham VA Medical Center, Durham, NC Objective: Drug-induced liver injury, although rare, is the leading cause of acute liver failure and has been associated with a variety of medications. The Veterans Health Administration (VHA) Drug-Induced Liver Injury Database Project applied new approaches to identify acute liver injury events following drug exposures using the electronic medical records (EMR). The purpose of this study was to utilize those approaches to deduce acute liver injury incidence associated with sulfamethoxazole/trimethoprim (SMZ/TMP) in the real world, as well as to identify risk disparities pertaining to age, gender, and race/ethnicity.

Methods: This study was a retrospective cohort analysis of data collected via the VHA EMR during the years 1999-2015. Incidence of acute liver injury, defined by laboratory data, following exposure to SMZ/TMP was computed and analyzed for the association with demographic characteristics using multiple logistic regression models.

Results: Approximately 900,000 patients were exposed to the study drug SMZ/TMP. For SMZ/ TMP exposed patients, most patients were male (88.8%), greater than 66 years of age (66.6%) and white (68.7%). Acute liver injury incidence for SMZ/TMP was 0.28% (95% confidence interval 0.27–0.29). In the multiple logistic regression, men and American Indian or Alaska Native were more likely to develop acute liver injury following SMZ/TMP. Conclusion: This study demonstrated high rates of acute liver injury following SMZ/TMP in comparison to prior literature. Risk disparities were found in acute liver injury following the exposure to SMZ/ TMP. A better understanding of risk disparities for SMZ/TMP will allow for more informed prescribing decisions and monitoring for future patients.

Title: Perceptions and Knowledge of Clinical Pharmacy Among Medical Residents in North Carolina

Authors: Payton Tipton, PharmD; Riley Bowers, PharmD, BCCP, BCPS; Autumn Mittleider, PharmD, BCPS, BCACP, CPP; Heather O’Brien, PharmD, CPP; Erika McClain, PharmD, BCACP, BCPS, CPP Institution: Cape Fear Valley Health System, Fayetteville, NC Objective: Limited data exists on the physicians’ perceptions of clinical pharmacists in the United States. In North Carolina, pharmacists can enter into collaborative practice agreements with physicians, allowing them to assume responsibility for patient care services that would normally be beyond their scope of practice. However, this type of collaboration will only be successful if each side sees the value that the other provides to the team and knows of the services that they can provide. The purpose of this study is to identify gaps in understanding of clinical pharmacy and opportunities to increase interprofessional collaboration.

Methods: This was a descriptive survey cohort study. The primary objective was to describe perceptions of clinical pharmacy services among medical residents. The secondary objectives were to describe the percentage of medical residents that have access to clinical pharmacy services and to compare the knowledge of available clinical pharmacy services by medical residents versus actual services provided as reported by pharmacists. Results: Forty-one medical residents in North Carolina completed the survey. Of these, 41.5% attended a private medical school with 75.6% have an MD degree. Majority of residents (58.5%) were a PGY3 or higher. Family medicine and emergency medicine residents were the most represented with 26.5% in each. One-hundred percent of residents felt that pharmacists were important or very important in answering drug information questions, while only 25% felt that pharmacists were important in vaccine administration. At least 50% of medical residents were aware of all pharmacy services available except for transitions of care, vaccine administration, and medication cost assistance.

Conclusion: Medical residents find pharmacist involvement to be most important in answering drug information questions. There is a continued need for education of medical residents on availability of pharmacy services.

Title: Acute liver injury following exposure to ciprofloxacin Authors: Rebekah Sowers, PharmD/MSCR Candidate Class of 2022, Sarah Wise, PharmD/MSCR Candidate Class of 2022, Avishek Nagi, Statistical Advisor, Dr. Melissa Holland, PharmD, MSCR, Dr. Ayako Suzuki, MD, PhD Institution: Campbell University College of Pharmacy & Health Sciences, Buies Creek, NC; Department of Medicine, Durham VA Medical Center, Durham, NC Objective: Acute liver injury following drug exposure, although rare, is the leading cause of acute liver failure and has been implicated with a variety of medications. The Veterans Health Administration (VHA) Drug-Induced Liver Injury Database Project engineered new approaches to identify acute liver injury events following drug exposures using electronic medical records (EMR). The purpose of this study is to utilize those approaches and deduce acute liver injury following ciprofloxacin exposure in the real world, as well as to identify risk disparities in acute liver injury incidence among age, gender, and race/ethnicity. Methods: This study was a retrospective cohort analysis of data collected from the VHA EMR

during the years 1999-2015. Incidence of acute liver injury, defined by laboratory data, following exposure to ciprofloxacin was computed and analyzed for association with demographic characteristics using multiple logistic regression models. Results: Approximately 1 million patients were exposed to ciprofloxacin between 1999 and 2015. Patients were mostly male (91.8%), greater than 66 years of age (72.8%), and white (69.7%). Acute liver injury incidence for ciprofloxacin was 0.41% (95% confidence interval 0.40–0.42). According to the multiple logistic regression, men, the black race group, as well as age groups 46-55 and 56-65 are more likely to develop acute liver injury following ciprofloxacin exposure. Conclusion: This study demonstrated higher incidence of acute liver injury following ciprofloxacin use compared to prior literature assessing other medications. Significant risk disparities in acute liver injury incidence were identified among study subgroups following exposure to ciprofloxacin. Understanding these risk disparities for ciprofloxacin will allow for more informed prescribing decisions and monitoring for future patients.

Title: Evaluation of Pharmacist-Led Behavioral Health Interventions to Improve Glycemic Control in Patients Managed by Atrium Health Internal Medicine Providers

Authors: Garfinkle, S. Nagy, K. Carson, P. Burleson, C. Cole, J. McKnight, K. Skaff, L. Wilkins, N. Institution: Atrium Health Cabarrus PGY1 Pharmacy Residency in the Ambulatory Care Setting; Concord, North Carolina Objective: The primary objective of this study is to evaluate the impact of pharmacist-driven telehealth services on antidepressant management in high-risk patients with the comorbid condition of diabetes.

Methods: This was a prospective, investigator-initiated pilot study conducted at 4 Atrium Health Cabarrus Internal Medicine sites. Eligible patients were gathered from Cerner/Powerchart based on ICD10 diagnosis codes congruent with diabetes, depression, and/or anxiety and with an A1c > 9%. Participants were excluded if they were under management by a private psychiatrist or Atrium Health’s Behavioral Health Integration Services. • Chart reviews were completed to assess drug-drug interactions, antianxiety/antidepressant medication regimen, diabetes medication regimen, and baseline labs/ screening tools. • Initial telehealth visits were conducted by the pharmacist to establish baseline, assess medication adherence and tolerance, and determine areas for intervention. • Recommendations were proposed to managing providers and implemented by pharmacist if approved. • Follow up telehealth visits were completed every 3-4 weeks and medications were adjusted as needed.

Results: Thirty-one patients were enrolled from December 2020 through March 2021. The majority of patients were followed through final hemoglobin A1c collection. While not finalized, results indicate significant improvement in A1c with pharmacist-led behavioral health and diabetes management interventions. Conclusion: Mood disorders tend to be overlooked when assessing barriers to achieving glycemic control in patients with diabetes mellitus. The utilization of a pharmacist in a setting that allows for observation and monitoring of anxiety or depression management can lead to improved diabetic outcomes and quality of life.

Title: Evaluation of direct oral anticoagulant (DOAC) to heparin transition strategy in the inpatient setting Authors: Sonam Patel, PharmD; Tina Hipp, PharmD, BCPS; Bobby Poplin, PharmD Institution: Atrium Health Cabarrus, Concord NC Objective: The purpose of this evaluation is to determine the current strategy being used at Atrium Health Cabarrus for transitioning patients from DOAC to therapeutic dose heparin in the inpatient setting and to assess its associated safety and efficacy. Methods: The Institutional Review Board at Atrium Health Cabarrus approved this retrospective chart review as a quality improvement project. Data was collected on adult patients who were transitioned from DOAC to therapeutic heparin between May 2020 to October 2020 and stored using the REDCap data collection tool. The primary outcomes of this evaluation include the reason for DOAC to heparin transition and the time between last DOAC dose and heparin initiation. Secondary outcomes include achievement of therapeutic aPTT and incidence of major bleeding and/or thromboembolic events.

Data from this evaluation was analyzed using descriptive statistics. Results: 52 of 132 patients screened met study inclusion criteria. Most patients were Caucasian males with an average age of 66 years. 52% of patients were transitioned to heparin in the setting of an upcoming procedure. The remaining patients were transitioned due to renal dysfunction (13%), NPO status (8%), or for other indications (27%) such as NSTEMI or acute thrombosis. Among those with clearly charted dose times, the average time to heparin initiation was 20.6 hours [median(IQR) = 14.8 (9-27.3)]. Therapeutic aPTT was achieved in 50% of patients. Bleeding occurred in 3 patients and thrombotic events occurred in 5 patients. No deaths due to anticoagulation were observed. Conclusion: This evaluation was unable to identify a consistent strategy being utilized by providers at Atrium Health Cabarrus with regards to the timing of heparin initiation. In most patients, heparin was initiated within 20 hours of the last DOAC dose. Despite inconsistencies with timing, bleeding and thrombotic events showed no clear association with early or delayed heparin initiation, respectively.

Title: Pharmacist-Led Medication Reconciliation Process Improvement in a Community Hospital General Medicine Unit

Authors: Benjamin Tutterow, Dustin Bryan, Susan Canady, Melissa Steedly, Savannah Knepper Institution: Cape Fear Valley Medical Center, Fayetteville, NC Objective: The primary purpose of this study was to determine the impact of a pharmacist-led medication reconciliation service for hospitalized patients on an internal medicine floor at a community hospital. This was determined by quantifying the number of interventions made during the medication reconciliation process. Secondary objectives were to further describe the types of interventions made, to describe the cost avoidance associated with these interventions, to describe the provider acceptance rate of these interventions, and to describe the amount of time required to complete the medication reconciliation process. Methodology: Participants included in this study were adults 18 years of age and older admitted to a general medicine unit. Included adult patients were admitted for 72 hours or less during the study period from October 1 to October 31, 2020 taking at least one scheduled medication prior to admission. The primary endpoint was the number of interventions related to medication reconciliation events conducted by a pharmacist. Secondary endpoints were types of interventions performed, amount of cost avoidance associated with each intervention, amount of time required to perform the medication reconciliation, and percentage of accepted interventions. Descriptive statistics were used to analyze the data of this study. Results: 17 total interventions were performed and accepted over the study period involving 3 intervention subtypes; drug/disease (5), drug/dose (4), and drug/ drug (1). Overall cost avoidance was $19000, mean time to perform the medication reconciliation was 21.2 minutes, and 58.8% of interventions were accepted. Conclusions: Pharmacist-led medication reconciliation resulted in few interventions, likely due to the study location and efficient emergency department pharmacy technicians. An inadvertent benefit in staff pharmacist workflow resulted from the use of documentation strategies developed in study.

Title: Improving the Transitions of Care from Intensive Care Unit to Step Down Unit Using Pharmacist Review

Authors: Andrea Lippucci, PharmD, Mike Maccia, PharmD, BCPS, BCCCP, Wesam Yacoub, MD, Randy Absher, PharmD, BCPS Institution: Moses Cone Memorial Hospital, Greensboro, North Carolina

Objective: To assess the impact of a clinical pharmacist’s review of medications at transfer from the intensive care unit (ICU) to assist with discontinuing select medications that were started for temporary indications during acute illness. This objective was measured with a primary outcome of total number of medications continued without an indication in both a retrospective and intervention cohort. Secondary outcomes assessed the primary outcome for each specific medication class and overall hospital length of stay. Methods: This IRB approved prospective case-control study with intervention arm was conducted in two medical ICUs in a community teaching hospital from September to December 2019 (retrospective) and September 2020 to January 2021 (prospective). Clinical pharmacists working in the ICU were educated on the

focus medications and possible interventions. Focus medication classes include antipsychotics/ anticonvulsants, opioids, benzodiazepines, stress ulcer prophylaxis agents, antibiotics, and steroids. When the intensivist suggested a patient would be transferred, the clinical pharmacist suggested discontinuing or tapering the focus medications no longer indicated. Results: Both cohorts included 35 patients. The average patient was 55 years old, male, and had a past medical history significant for diabetes or COPD/asthma. Within the control group, 29 medications for 18 patients were continued without an indication at transfer. In the intervention arm, 3 medications were continued without an indication in 2 patients (p <0.001). There were statistical differences in the number of opioids (p=0.01), stress ulcer prophylaxis agents (p<0.001), and antibiotics (p=0.039) inappropriately continued. There was no statistical difference in continuation of antipsychotics, anticonvulsants, benzodiazepines, or steroids. Conclusion: A pharmacist’s review of medication lists before transferring from the ICU can yield statistically significant differences in discontinuation or de-escalation of therapy, specifically with opioids, stress ulcer prophylaxis agents, and antibiotics. These results align with previous studies showing reduction of inappropriate medication continuation at transfer from the ICU.

Title: Impact of discharge antibiotic prescription review on appropriate empiric antibiotic prescribing in a community hospital emergency department Authors: Felmer AC, Simpson H, Kilburn J, Malloy V, Thakkar D, Crawford M, Bowers RD Institution: Cape Fear Valley Medical Center—Fayetteville, NC Background/Purpose: Antimicrobial stewardship efforts in the emergency department (ED) are generally focused towards the inpatient setting. As half of outpatient medical care occurs in emergency departments, we sought to implement an outpatient-focused antimicrobial stewardship effort. The aim of this study was to evaluate the impact of a prescription review process on improving appropriate empiric antibiotic prescribing at discharge from the ED at a community hospital. Methodology: In October 2020, a prospective discharge antibiotic prescription review process was implemented in the ED. Discharge antibiotic prescriptions were routed to the ED pharmacist verification queue and evaluated based on patient-specific parameters and current infectious disease guidelines. When prescribing issues were identified, the prescriber was contacted with new recommendations. A review was implemented to analyze prescriptions for two months before the new service implementation and two months after. Prescriptions that met initial screening criteria during each timeframe were randomly selected to include 260 prescriptions in each group. The primary endpoint was rate of appropriate empiric antibiotic prescriptions based on indication, drug, dose, and duration. Time in the emergency department and 30-day revisit rates were also compared between the groups. Results: The implementation of a prospective prescription review process significantly increased the number of appropriate antibiotic prescriptions compared to before the service (80.0% vs. 58.4%, p <0.0001). Each component of the primary endpoint was also significantly increased with the exception of appropriate antibiotic based on patient-specific factors. Patient time in the emergency department was not extended by the implementation of this new service as the mean time spent in the ED before the service was 244.2±282.0 minutes compared to 215.2±179.6 minutes after (95% CI [-69.81 to 11.84], p=0.1636). Conclusions: A prospective prescription review process was effective in increasing the rate of appropriate antibiotic prescriptions written for patients discharging from a community hospital ED without increasing the duration of visit.

Title: Impact of Curbside Warfarin Monitoring on Appointment Attendance and Patient Satisfaction at an Urban Outpatient Clinic during the COVID-19 Pandemic Authors: Kathleen Macalalag, PharmD1,2, Carrington Royals, PharmD Candidate 20212, Jessica King, PharmD Candidate 20212, Autumn Mittleider, PharmD, BCACP, BCPS, CPP1,2, Erika McClain, PharmD, BCPS,BCACP, CPP1,2 Institution: Cape Fear Valley Health, Fayetteville NC; Campbell University College of Pharmacy & Health Sciences, Buies Creek NC Objective: The primary purpose of our study was to compare patient attendance at warfarin monitoring appointments prior to and following the implementation of our curbside INR service. Secondary objectives were

to identify any relationship(s) between the number of comorbid conditions that increase risk of severe infection with COVID-19 and attendance at warfarin monitoring appointments during the COVID-19 pandemic, to describe patient satisfaction with our curbside service, and to describe patients’ perceptions of length of curbside warfarin visits compared to in-clinic warfarin visits.

Methods: This single-centered, historical control study included patients of a family medicine clinic that completed at least one pharmacist-managed curbside INR visit between April 1, 2020 to September 30, 2020. Patients that declined to complete our survey, were not on warfarin therapy, or were missing data necessary for the primary endpoint were excluded. Data collected included patient demographics, indications for warfarin, conditions that increase risk of severe infection with COVID-19, number of warfarin appointments scheduled/canceled, and survey responses. Results: Prior to implementing a curbside INR service, 9.1% of forty-two patients canceled warfarin monitoring visits compared to 8.9% following implementation (p=1.00). Of these canceled appointments, 19.4%, 77.4%, and 3.2% of patients had 3, 1 or 2, or no comorbidities that increased the risk of severe COVID-19 infection, respectively. Forty-two surveys were completed: 95.2% of respondents were satisfied with our curbside INR service, 2.4% had neutral satisfaction, and 2.4% were dissatisfied. Overall, respondents felt that curbside INR visits were shorter than in-clinic INR visits.

Conclusions: Curbside INR visits maintained attendance at the pharmacist-led INR monitoring service despite the COVID-19 pandemic. The majority of patients were satisfied with our service and 88.1% of respondents indicated that they would like curbside INR visits to continue after COVID-19 social distancing requirements become less strict.

Title: A Psychiatric Presentation of Antiepileptic-Induced Aseptic Meningitis Authors: P. Brittany Vickery, PharmD, BCPS, BCPP, CPP; J. Kyle Roach, Doctor of Pharmacy Candidate 2023; Stephen Vickery, PharmD, BCPS Institution: Wingate University School of Pharmacy, Wingate NC Introduction: Aseptic meningitis is described as meningeal inflammation not occurring from a bacterial cause. While uncommon, this condition may arise from antiepileptic use (antiepileptic-induced meningitis or AEIM). Only three drugs in this class have documented cases: lamotrigine, carbamazepine, and levetiracetam. This report highlights one of only two suspected cases of AEIM with levetiracetam use.

Case: A 54-year-old gentleman presented with hypersomnolence and altered mental status, specifically confusion. The patient was previously given levetiracetam at a different facility after presenting with possible seizure and he had not received recent antibiotics. On day one, the patient had no nausea/vomiting, headache, fever, neck pain, and rash. Brain MRI scan was negative and serology tests (ANA and dsDNA) showed no detection. On day two, levetiracetam therapy was stopped and replaced with lacosamide, and a lumbar puncture was performed for CSF analysis which revealed lymphocytic pleocytosis, high protein, and slightly high glucose, notably. Acyclovir 1000 mg intravenous was also initiated. By day three, CSF cultures were negative, and the patient’s symptoms had drastically improved after stopping levetiracetam. The patient was discharged on day four with orders to continue acyclovir orally for seven additional days. Discussion: Aside from altered mental status, the patient did not present with any other symptoms of AEIM. CSF analysis was performed to exclude other causes. Results of the analysis strongly correlated with a drug-induced cause, but they also mimicked a viral cause, leading to empiric acyclovir therapy. CSF lymphocytic pleocytosis (commonly seen in viral meningitis) led to suspicion of a possible viral cause, despite the correlation to AEIM. Improvement of symptoms two days after stopping levetiracetam was a very important sign for suspected AEIM. All other reports of meningitis from antiepileptic use highlighted symptom resolution a few days after discontinuing the offending agents. Clinicians who prescribe antiepileptics should always consider AEIM.

Title: Lipase Elevation and Subsequent Resolution with Continued Injectable Semaglutide: A Case Report Authors: 1Ryan Kendall; 2,3Cortney Mospan, PharmD, BCACP, BCGP; Patrick Fillnow, MD3 1University of Georgia, Athens, GA 2Wingate University School of Pharmacy, Wingate, NC 3Novant Health Internal Medicine Providence, Charlotte, NC Introduction: Lipase and amylase levels have been found dose-in-

dependent, reversible events that have little predictive value for risk of acute pancreatitis. Lipase elevations have been found to occur in approximately 33% of patients taking liraglutide, yet only 0.3% of patients developed acute pancreatitis. No data is available regarding the clinical significance of lipase elevation with injectable semaglutide. Case: A 79 year-old male with type 2 diabetes, hypertension, hyperlipidemia, macular edema, and merkel cell carcinoma was started on injectable semaglutide 0.25 mg once weekly. Other diabetes medications at treatment initiation included metformin ER 1000 mg twice daily and glipizide 10 mg twice daily. One week after injectable semaglutide was initiated, elevated lipase (259 U/L) and normal amylase (46 U/L) levels were identified as part of routine monitoring related previous chemotherapy for treatment of merkel cell carcinoma. A CT scan showed no evidence of acute pancreatitis and the patient endorsed no symptoms of acute pancreatitis. Since the patient was asymptomatic, injectable semaglutide was continued. Three weeks later, lipase (47 U/L) and amylase (29 U/L) were within normal limits. The patient was able to be successfully titrated to semaglutide 1 mg once weekly without developing acute pancreatitis. Discussion: The findings of this case report are consistent with available literature with liraglutide showing that lipase elevation is a poor predictor of risk of acute pancreatitis and glucagon-like 1 peptide receptor (GLP-1) agonists can be continued without significant risk if lipase and/or amylase elevations are identified. This case demonstrates resolution of lipase elevations without treatment discontinuation of injectable semaglutide. Routine lipase and amylase level monitoring should not be utilized in GLP-1 therapy monitoring due to poor predictive risk of acute pancreatitis and potential to cause unwarranted short-term or permanent cessation of the medication.

Title: Successful Concomitant Use of Oral Semaglutide with Levothyroxine to Achieve Glycemic Control: A Case Report Authors: Alexis Jones1, PharmD Candidate; Cortney Mospan1,2, PharmD, BCACP, BCGP; Patrick Fillnow2, MD 1Wingate University School of Pharmacy, Wingate, NC 2Novant Health Internal Medicine Providence, Charlotte, NC Introduction: In September 2019, the US Food and Drug Administration approved the first oral glucagon-like peptide 1 receptor agonist. Use of oral semaglutide in patients taking levothyroxine presents a challenge as both medications are advised to be taken first thing in the morning, on an empty stomach. This is the first case study to describe concomitant use of oral semaglutide and levothyroxine and the impact on diabetes mellitus and hypothyroidism outcomes. Case: A 52 year-old female with diabetes and hypothyroidism was started on oral semaglutide 3 mg daily and ultimately titrated to 14 mg daily. Other concomitant therapies included empagliflozin 25 mg daily, metformin ER 1000 mg twice daily, pioglitazone 45 mg daily, and levothyroxine 25 mcg daily. A1c at treatment initiation was 11.9%, which decreased to 5.4%. TSH level at oral semaglutide initiation was 2.23 uIU/mL and 2.37 uIU/mL after approximately six months of therapy. No changes in hypothyroidism symptoms were noted.

Discussion: There are no case reports describing concomitant use of oral semaglutide with levothyroxine; however, clinical drug interactions studies have shown levothyroxine exposure to be increased by 33% when co-administered with oral semaglutide. In our patient, TSH level showed a slight decrease, suggesting increased levothyroxine exposure. However, this was not clinically significant and the patient’s TSH stayed within range with no changes in related symptoms. Following the stated package insert guidance of taking oral semaglutide 30 minutes before any food, drink, or medication administration resulted in significant A1c lowering. As a result, initiating oral semaglutide concomitantly with levothyroxine had no clinically significant impact on TSH level or hypothyroidism symptoms. The patient was able to successfully meet

Title: Examination of Pharmacists’ Support for Implementation of Syringe Exchange Programs in Community Pharmacies in North Carolina: A Social Ecological Approach Authors: Heather H. Roberts, PhD, RN, MSN; Debra C. Wallace, PhD, RN, FAAN; Anna Stein, JD, MPH; Amanda Isac, PharmD, MPH; Acknowledgements: Ratchneewan Ross, PhD, RN, FAAN; Robin Bartlett, PhD, RN; Mark Schulz, PhD Institution: University of North Carolina at Greensboro

Objective: This study examined NC community pharmacists’ sup-

port of implementation of syringe exchange programs in community pharmacies and factors associated with support. Methods: This cross-sectional study was guided by the Social Ecological Model. NC community pharmacists (N = 304) were surveyed using an online survey. Frequencies, proportions, Somers’ d, PLUM ordinal regression, and Chi-squared analyses were used to answer 6 research questions. Results: More than two thirds of NC community pharmacists support implementation of a syringe exchange program in their pharmacy to some extent. Factors most strongly associated with support were beliefs about syringe exchange programs, receiving education on syringe exchange programs, type of community pharmacy, concern about having increased numbers of injection drug users in the pharmacy, and receiving training on how to implement a syringe exchange program. Factors predicting support were type of community pharmacy (independent/chain), gender, and years of practice. Support and factors differed between chain and independent community pharmacists. Chain community pharmacists were 56.1% less likely to express support to a greater extent compared to independent community pharmacists. Chain community pharmacists had fewer beliefs about the effectiveness of syringe exchange programs and more concerns associated with implementation. Male community pharmacists were more likely to support implementation to a greater extent as were community pharmacists with 11 to 20 years of practice. Conclusions: NC community pharmacists support pharmacy-based syringe exchange programs to some extent. Concerns and some lack of knowledge of the overall potential public health impact of syringe exchange programs existed and stigmatization of injection drug users was suggested. Strategies to mitigate concerns and increase knowledge about syringe exchange programs and implementation processes and to reduce stigma are warranted. Community pharmacists and public health nurses provide an excellent collaborative engagement to develop and implement these strategies.

Title: The Impact of COVID-19 on Social Media use Among Pharmacy Student Organizations Authors: Kiarra Bowser, PharmD Candidate, Susan M. Smith, BS, PharmD, BCPS Institution: Wingate University School of Pharmacy, Wingate, NC Objectives: Throughout the COVID-19 pandemic, pharmacy students changed how they learn and communicate. The primary objective of this study was to determine whether students found pharmacy student organization social media content beneficial. The secondary objective was to determine what organizations had the greatest student following and assess whether social distancing barriers impacted the number of social media postings. Methods: Facebook and Instagram posts in Fall semesters 2020 and 2019 by 13 student pharmacy organizations were retrospectively reviewed (March 2021) to determine the overall number of posts. Additionally, a survey was distributed to 146 second- and third-year pharmacy students (80 and 66, respectively) to determine their perceptions of social media postings made by organizations. Perception data captured included frequency of checking posts, usefulness of posts, and student use in 2020 compared to 2019. Results: Nine (69%) student organizations made 597 posts on social media (Fall 2020 [n=403, 68%] and Fall 2019 [n=194, 32%]). SNPhA posted the most in 2020 (n=295, 73%) and 2019 (n=63, 32%). Survey response rate was 47% (n=68). Most of the survey respondents belonged to APhA-ASP (n=32, 47%), NCAP (19, 28%), and SNPhA (n=19, 28%). All students who belonged to SNPhA (n=19) and KE (n=13) followed their organizations’ social media sites. Students followed their organizations on a weekly basis (n=43, 43%) and found the posted information to be extremely useful (n=39, 39%) or somewhat useful (n=48, 48%). Students utilized social media about the same in 2020 compared to 2019 (n=46, 46%). Forty (40%) students stated they used social media more in 2020 compared to 14 (14%) in 2019. Conclusions: Overall, social media posting was higher in 2020. Additionally, students appeared to rely more on social media to receive information about their organizations during the fall semester of the pandemic compared to the previous year.

Title: Impact of outpatient transitions of care pharmacy program on interventions for discharged patients in a community hospital Authors: Tiffany Kahl, PharmD1,2, Amanda Wright, PharmD1, Deanna Benz, PharmD, BCOP1, Elizabeth Hudson, PharmD, MBA1, Heather McLeod,

PharmD, BCACP1, Taylor Wells, PharmD, MBA1, Emily Ghassemi, PharmD, BCACP, CDE, CPP2 Institution: Cape Fear Valley Medical Center, Fayetteville NC; Campbell University College of Pharmacy & Health Sciences2, Buies Creek NC

Objective: In August 2020, Cape Fear Valley Medical Center (CFVMC) implemented a transitions of care (TOC) pharmacist position in order to facilitate successful patient transitions from inpatient to outpatient care. The purpose of this project was to describe the clinical impact of the discharge process and the potential need for additional TOC pharmacists in this role. Methods: This was a single-centered retrospective chart review including patients discharged from CFVMC through the discharge lounge between 09/01/2020 and 12/1/2020. The primary objective was describing intervention types made by the TOC pharmacy staff on discharge prescriptions. Secondary objectives were to determine the number of patients requiring interventions, acceptance rate of interventions requiring provider approval, and time spent on interventions.

Results: There were 6,185 patients discharged through the discharge lounge between 09/01/2020 and 12/1/2020. 563 discharge medication interventions were completed by the TOC pharmacy staff on 440 unique patients. The most frequent intervention types were preventing medication error (38.1%), addressing socioeconomic barriers (21.8%), and providing medication optimization (19.3%). It took pharmacy staff less than 10 minutes to complete 77.7% of interventions and more than 10 minutes to complete the remaining 22.3%. Eighty-six percent of interventions requiring provider approval were accepted. Conclusions: The implementation of a TOC process has resulted in various types of interventions, which help to facilitate patient transition from inpatient to outpatient care. Future studies could be designed to assess patient outcomes associated with the implementation of TOC pharmacist(s).

Title: Anaphylaxis Case Report to Oral Semaglutide and Extended Release Exenatide

Authors: Alicia Guthrie, PharmD, MBA; Lindsay Sheehan, PharmD, CDCES, CPP Institution: Atrium Health, Concord, NC Introduction: Glucagon-like peptide 1 receptor agonists (GLP-1 RA) are a mainstay of therapy for patients with type 2 diabetes mellitus (T2DM). Common adverse reactions of GLP-1 RAs are gastrointestinal (GI) side effects such as diarrhea, constipation, nausea, and abdominal pain; however, anaphylaxis is listed as a possible adverse reaction. This report details two patients who experienced anaphylaxis while taking oral semaglutide and extended release exenatide, respectively. Case(s): The first patient is a 56-year-old male who was initiated on oral semaglutide for T2DM and weight loss. It was known that he had previously taken liraglutide and dulaglutide but had not tolerated due to GI upset. The patient was interested in retrying another GLP-1 RA so oral semaglutide 3mg once daily was initiated. After 30 days, his dose was increased to 7mg daily. Almost two weeks after he increased to 7mg, he experienced “sour stomach”, diarrhea, itching of the hands, and eventually swelling of his throat. He became unresponsive and was transported to the emergency department where he was treated for anaphylaxis with epinephrine and steroids. The second patient is a 53-yearold female who was initiated on extended release exenatide for T2DM and weight loss. She had previously taken liraglutide, but did not report any adverse effects from it. A few hours after her second dose of exenatide she started to experience shortness of breath, leg and lip swelling, headache, and urticaria. She was taken to the emergency department where she was treated with fluids, antihistamines, and steroids. Discussion: These cases highlight that anaphylactic reactions can present in several ways. While GI upset is a common side effect of GLP-1 RAs, it can also be a symptom of anaphylaxis in some patients. It is important to recognize potential signs of allergic reactions, especially those that are less common or obvious.

Title: Evaluation of Pharmacist Integration into Migraine Management within Primary Care Practices

Authors: Rachel Trimmer, PharmD, Dawn Caviness, MD, BSN, CDE, Paige Carson, PharmD, CDCES, BCPS, CPP, Lydia Wang, PharmD, BCPS, BCACP, DPLA, CPP, Lindsay Sheehan, PharmD, CDE, CPP, Kayla Morgan, PharmD, BCACP, CDCES, CPP, Lauren Downing, PharmD Institution: Cabarrus Family

Objective: The primary purpose of this study is to evaluate the impact of pharmacist integration into migraine management within Atrium Health primary care practices. Methods: The medical records of 61 patients with clinically diagnosed migraine from December 2020 to early April 2021 were reviewed. Patients under the age of 18 and/or patients currently being managed by a neurologist or headache specialist were excluded. A pharmacy resident chart reviewed each patient, conducted an initial migraine assessment, and proposed recommendations for medication therapy optimization to individual primary care providers. Accepted therapy recommendations were implemented by the pharmacist, and follow-up assessments were completed monthly by the pharmacist to assess for tolerability and efficacy of the medications. Data collected included patient demographics, current and previously failed migraine therapies, baseline and follow-up migraine frequencies, provider referrals, and acceptance/denial of pharmacotherapy recommendations. Results: Sixty-one patients underwent the initial migraine assessment. Pharmacist identified thirty of these patients as candidates for medication therapy optimization. Medication adjustments included addition, titration, or change in current acute and prophylactic migraine treatments based on current guidelines for migraine management. While not finalized, results indicate reduction in migraine frequency, improved utilization of guideline directed therapies, and improved access to medications with pharmacist-led Conclusion: Despite being an extremely prevalent and disabling neurologic disorder, migraine tends be either overlooked and/or undertreated. The utilization of a pharmacist in a setting that allows for observation and monitoring of migraine management can lead to improved migraine outcomes and overall quality of life.

Title: Evaluation of Antibiotic Use in Patients with Gram Positive Bacteremia After Implementation of a Rapid Diagnostic Blood Culture Panel with Pharmacist Review

Authors: Thomas Sessoms, PharmD, Toni Pate, PharmD, Thomas Brown, PA-C, Serina Tart, PharmD Institution: Cape Fear Valley Medical Center

Objective: The primary purpose of this study was to evaluate the impact on the time to targeted therapy in patients with gram positive bacteremia after implementation of a rapid diagnostic blood culture panel (Biofire Blood Culture Identification Panel BCID2TM) with pharmacist review compared to traditional testing. Secondary objectives were to compare: mean time to organism identification; hospital wide days of therapy/1000 patient days (DOT) for vancomycin, daptomycin, and linezolid; and length of stay. Methods: This retrospective, quality improvement cohort study included patients admitted at a large community hospital from December 1, 2020 to February 28, 2021 with gram positive bacteremia identified by the BCID2. BCID2 testing started November 3rd, 2020 and a select group of pharmacists were educated/provided with a standardized algorithm for antibiotic recommendations. Comparison of endpoints were made to a control group of patients with gram positive bacteremia admitted July 1, 2020 to September 30, 2020 prior to BCID2 implementation. Data was collected on patient pre-existing conditions.

Results: The control group had 101 patients that met inclusion criteria, with a mean of 89.1 hours to targeted therapy; mean length of stay 3.7 days and mean time to bacteria identification 88.5 hours. The mean DOT for intravenous vancomycin in July-September compared to December-February was 65.7 to 60.9, for daptomycin 7.83 to 6.69, and for linezolid 16.4 to 16.4. There were 161 patients identified that met inclusion criteria in the post-intervention group, with data collection in progress and statistical analysis pending. Conclusion: In progress

Title: Impact of pharmacist-provided telehealth management of diabetes on HbA1c pre-COVID-19 and during the COVID-19 pandemic

Authors: Lindsy Coan, Pharm.D., BCACP, CDE [Principal Investigator]; Angela Porter, Pharm.D., BCACP, CDE [Co-Principal Investigator]; Shekinah Baum, Pharm.D. [PGY1 Resident, Study Coordinator] Institution: Charles George VA Medical Center (Western North Carolina VA Healthcare System) Objective: The primary objective of this evaluation was to assess the change in HbA1c in patients