2023 RESEARCH SHOWCASE ABSTRACTS Pharm.D. STUDENTS

The Effect of Decreased Renal Function on Hemoglobin A1C Goals in Men with Diabetes

Bret Abreu PharmD. Candidate, Celina Chau PharmD. Candidate, Jack Dolan PharmD. Candidate, Nick Mcpadden PharmD. Candidate, Rebecca O’Toole PharmD. Candidate

Purpose:

Current data identifies uncontrolled diabetes and elevated hemoglobin A1C (HbA1C) as risk factors for chronic kidney disease (CKD)1,2,3 Supporting patients’ in meeting HbA1C goals is essential to improving health outcomes and preventing CKD2,3. Patients with diabetes and CKD are at significantly increased risk for cardiovascular disease 1,3,4, Previous studies show that CKD does not impact HbA1C 5. Our goal is to determine if a relationship between decreased renal function and ability to meet HbA1C goals exists.

Methods:

This cross-sectional study utilized data collected from the 2017-2018 National Examination Survey (NHANES). Decreased renal function was defined as creatinine clearance (CrCl) less than 60mL/min via the Cockcroft-Gault equation. The outcome was defined as a measured HbA1C above the goal. Male patients aged 18-79 years old with a diagnosis of diabetes were included and patients with missing/unknown values were excluded; yielding a total of 226 patients. A Chi square test and multivariable logistic regression with a one sided T-test (ɑ = 0.05) was conducted using SPSS to evaluate whether decreased kidney function impacts success in meeting HbA1C goals.

Results:

84% of patients (N=190) had a CrCl above 60mL/min and 15% (N=36) had a CrCl below 60mL/min. 87% (N=128) of patients with a CrCl above 60mL/min and 52% (N=19) of patients with CrCl below 60mL/min, did not meet their HbA1C goal. Patients with a CrCl below 60 ml/min are 58% less likely to reach their HbA1C goal (95% CI 0.151-1.167; p = 0.096).

Conclusion: There was no significant difference in the odds of achieving target A1C levels for males between the age of 18-79 years old in those who have poor renal function compared to those who do not have poor renal function.

Comparison of Blood Pressure Values Associated with Lisinopril and Amlodipine Use in Patients with Hypertension Who Smoke Cigarettes, E-Cigarettes, or Use Smokeless Tobacco

Michael Akon, Pharm.D. Candidate, Chris Bracchi, Pharm.D. Candidate, Claire Burbridge, Pharm.D. Candidate, Katie Hong, Pharm.D. Candidate, Elisa Quinones, Pharm.D. Candidate

Purpose:

The nicotine in cigarettes, e-cigarettes, and tobacco may increase blood pressure (BP) and contribute to hypertension. Amlodipine, a calcium channel blocker (CCB), and lisinopril, an angiotensin-converting enzyme inhibitor (ACE-I) are first-line treatment options for hypertension. The objective of this study was to compare the clinical efficacy of amlodipine and lisinopril among patients with hypertension that smoked or used smokeless tobacco through BP values.

Methods:

This national cross-sectional retrospective study included patients taking amlodipine or lisinopril from the National Health and Nutrition Examination Survey (NHANES) of the 20172018 cycle. Inclusion criteria included being diagnosed with hypertension, defined as BP values over 130/80 mmHg and smoking cigarettes, e-cigarettes, or using smokeless tobacco. Exposure was defined as the use of either amlodipine or lisinopril. Outcome was defined as the efficacy of these medications, indicated by BP. A logistic regression analysis adjusted for multiple covariates was used to compare BP values and obtain an odds ratio among both amlodipine and lisinopril users.

Results:

253 individuals diagnosed with hypertension were included, of which 205 were taking amlodipine and 48 were taking lisinopril. Among the amlodipine and lisinopril users, 68 (33.2%) and 21 (43.7%) had BP values less than 130/80, respectively. The odds ratio of 0.673 suggested that lisinopril users were about 33% less likely to have hypertension. However, the p-value (significance level = 0.05) of 0.167 suggested that there was no significant difference between the two medications.

Conclusion:

Although the study demonstrates that lisinopril may have better anti-hypertensive effects, a future study with a larger sample size is warranted to demonstrate an effect. Limitations to the study included not incorporating data on other medications, not identifying all potential risk factors and covariates, and not having data on specific BP values before and after using the medications.

The Effects of Levothyroxine use on Femoral Neck Bone Mineral Density and the Associated Risk of Osteoporosis Development

Dennis Angjeli Pharm.D. Candidate, Emily Lancor Pharm.D. Candidate, Kamryn Montague Pharm.D. Candidate, Daniel Radev Pharm.D. Candidate, Hannah Sears Pharm.D. Candidate

Purpose:

Levothyroxine (Synthroid) is the most common medication prescribed for the treatment of hypothyroidism and the second most commonly prescribed medication in the US1, 2. However, overreplacement of thyroid-stimulating hormone potentiates an association with decreased bone mineral density (BMD), putting patients at a higher risk of developing osteoporosis3. Some studies have been performed, but results have been inconclusive4, 5 . The purpose of this study is to determine if levothyroxine use puts patients at an increased risk of developing osteoporosis, based on their femoral neck BMD.

Methods:

This cross-sectional study used data from the 2017-2018 National Health and Nutrition Examination Survey (NHANES). A logistic regression was run that adjusted for confounders. A Pearson’s Chi Square test or Fisher’s Exact test (where counts ≤5) were used to obtain P values for categorical variables. A one sided T test was used to obtain P values for continuous variables. The significance level for all tests was 0.05.

Results:

Among the 2,014 participants who received a DXA scan, 5.1% reported taking levothyroxine (n=103). In the levothyroxine group, 75.7% (n=78) were female and 24.3% (n=25) were male ( p <0.001). The average femoral neck BMD in patients taking levothyroxine was 0.75g/cm2 and 0.77g/cm2 in patients not taking levothyroxine (p <0.001). More patients on levothyroxine had a lower BMD (68% vs. 60.9%), however, the results were not significant (p = 0.152). There was no significant increase in risk of osteoporosis development in those who use levothyroxine (OR: 1.096, 95% CI: 0.696-1.723).

Conclusions:

These results suggest that levothyroxine does not affect BMD while also accounting for age, gender, and past medical history. These findings are consistent with the limited studies that have been published, however, more studies are needed for confirmation.

Does Anxiety Increase the Rate of Asthma Exacerbations in Patients with Asthma?

Matthew Armanus PharmD. Candidate, Connor Manning PharmD. Candidate, Emily Minella PharmD. Candidate, Tara Neary PharmD. Candidate, Vivian Tran PharmD. Candidate

Purpose:

Studies evaluating the rates of psychological triggers in patients with asthma and concurrent anxiety are limited. Existing data has demonstrated that anxiety and symptoms of anxiety in asthmatic patients were associated with higher rates of uncontrolled asthma and poorer quality of life scores. This study aimed to determine if anxiety increases asthma exacerbation rates in asthmatic patients.

Methods:

A cross-sectional survey design was used with data collected from the 2017-2018 NHANES questionnaire. Inclusion criteria included participants over the age of 18 that had a diagnosis of asthma with or without medication therapy for anxiety. Exclusion criteria included participants without an asthma diagnosis and those with asthma who did not have feelings of “worried, nervous, or anxious”. A binary logistic regression was used and adjusted for multiple covariates to generate an odds ratio (OR) and compare against the exposure group with 95% confidence intervals. A Pearson's Chi-square test and a paired t-test was used to generate P values for categorical variables and continuous variables, respectively.

Results:

Among 102 participants that took medications for anxiety, 54.9% (56/102) experienced an asthma attack in the past year compared to 39.2% (169/431) for participants who did not take medications for anxiety. The risk of experiencing an asthma attack in the past year in patients medicated for anxiety was 1.89 times (95% CI 1.22 - 2.92; p-value = 0.004) higher than those non-medicated for anxiety.

Conclusion:

The results of the study were statistically significant showing that patients taking medication for anxiety were more likely to have had an asthma attack within the last year. Limitations included using a cross sectional study, unknown medication adherence, recall bias, and unknown definitive anxiety diagnosis. Future research correlating anxiety severity and medication therapy to asthma exacerbations are needed to further strengthen the conclusion

Comparing Low-Density Lipoprotein Cholesterol (LDL-C) Levels Between Tobacco Users and Non-Tobacco Users

Olivia Arukwe PharmD. Candidate, Alexandra DeSantis PharmD. Candidate, Julia Fey PharmD. Candidate, Ethan Gentile PharmD. Candidate, Sophia Pantano PharmD. Candidate

Purpose:

Approximately 12.5% of US adults currently use tobacco. Smoking increases LDL-C, an important marker for CVD, increasing risk for adverse cardiac events. Literature addresses effects of cigarettes, e-cigarettes, and smokeless tobacco separately on LDL-C. This study groups cigarettes, e-cigarettes, or smokeless tobacco users' effects on LDL-C levels.

Methods:

2017-2018 NHANES data was used. A chi-square, independent t-test, and multivariable linear regression were conducted using SPSS. Those who said yes to using cigarettes, e-cigarettes, or smokeless tobacco and whose LDL-C levels were recorded using the Friedewald equation (mg/dL) were included. Exclusions included those who said no to using cigarettes, e-cigarettes, or smokeless tobacco and whose LDL-C wasn't recorded. Covariates included age, gender, BMI, SBP (mmHg), and fasting glucose (mg/dL). The outcome of interest was clinically abnormal LDL-C (>130 mg/dL).

Results:

There’s a significant difference between tobacco and non-tobacco users regarding gender and BMI. There’s no significant difference between LDL-C >130mg/dL and tobacco versus nontobacco users. After controlling for confounders, there’s no significant difference in LDL-C >130mg/dL between tobacco users versus non-tobacco users. It’s significant that each SBP category is more likely to have LDL-C >130mg/dL versus the reference. It’s significant that fasting glucose > 126mg/dL is less likely to have LDL-C >130mg/dL versus the reference.

Conclusions:

There’s no significant difference between LDL-C > 130mg/dL and tobacco users versus nontobacco users. While our data consisted of a large sample, it may not represent the population. We didn’t assess the role diet played on LDL-C, nor if patients took cholesterol medications or exercised. With limited research about impacts of e-cigarettes on LDL-C, this is a future research direction.

Prevalence of Hypertension in Patients with History of Adverse Cardiovascular Events: A Cross Sectional Study

Purpose:

Almost 50% of American adults experience hypertension (HTN), 80% being uncontrolled.1,2 Hypertension, defined as SBP >130mmHg or DBP >80mmHg, is linked to an increased risk of adverse cardiovascular events (CVE).2,6 A meta-analysis of 61 prospective studies found increases of 20mmHg SBP or 10mmHg DBP were associated with doubled risk of death from CVE.3,4 The objective of this study was to assess prevalence of hypertension in those who experienced a CVE.

Methods:

A cross sectional study was performed using National Health and Nutrition Examination Survey (NHANES) data of 5,542 US adults enrolled between 2017-2018. A CVE was defined as congestive heart failure, coronary heart disease, angina, heart attack, or stroke. Participants with missing/unknown values were excluded. Multivariable regression was performed to assess covariate influences (age, BMI, diabetes, dyslipidemia, smoking)5 .

Antihypertensive medication impact was excluded due to limited information, requiring further analysis.

Results:

Of 5,542 individuals, 644 patients experienced a CVE with 45% of those having hypertension. Between those experiencing a CVE and not, there were statistically significant differences in baseline characteristics (age, gender, race, BMI, weight, dyslipidemia, diabetes, smoking status).

Initial analysis shows increased prevalence of HTN in those having experienced CVE (OR 1.607, p <0.001). Covariate adjustment demonstrated statistically significant impact of confounders and no significance between prevalence of HTN and CVE (adjOR 1.061, p = 0.550).

Conclusion:

No statistically significant relationship between CVE and prevalence of hypertension was demonstrated following covariate adjustment. Limitations included lack of potential confounder information, confounder prevalence, and data restrictions. Further studies, removing covariates, are needed to determine the relationship between HTN and CVE.

Comparison of Urinary Incontinence in Individuals with Abnormal CrCl Taking Loop Diuretics versus Thiazide Diuretics

Jason Baldinger PharmD. Candidate, Jordan Caro PharmD. Candidate, Amanda Lin PharmD. Candidate, Katie Post PharmD. Candidate, Ashley Wilson PharmD. Candidate

Purpose:

Creatinine clearance is a measure of kidney function and approximates filtering rate of creatinine in the kidneys. Generally, a creatinine clearance below 90 mL/min indicates decreased kidney function. Medications, such as loop and thiazide diuretics, can increase urine production in the body. This study aimed to assess the incidence of urinary leakage in individuals with abnormal creatinine clearance, defined as less than 90 mL/min, who are taking a loop or thiazide diuretic.

Methods:

Data from the National Health and Nutrition Examination Survey (NHANES) was evaluated for individuals with kidney conditions taking diuretic prescription medications between 2017 and 2018. Inclusion criteria included individuals with abnormal CrCl defined as < 90 mL/min taking either a loop or thiazide diuretic. Loop diuretics included furosemide, bumetanide, and torsemide. Thiazide diuretics included hydrochlorothiazide, chlorthalidone, and indapamide. The outcome of interest was incidence of urinary incontinence, defined by self-reported urinary leakage. Statistical tests performed to evaluate the effect of different diuretic classes on urinary incontinence included Pearson Chi-Square tests, single sample t-tests, and logistic regression.

Results:

There were 91 individuals in the study who met eligibility criteria. The logistic regression showed loop diuretic users were approximately 25% less likely (OR = 0.755) to have incidence of urinary leakage compared with thiazide users but yielded p = 0.594 meaning this result was statistically insignificant. Comparing the frequency of urinary leakage within the population yielded p = 0.179 which is also statistically insignificant.

Conclusions:

The study findings concluded the incidence of urinary incontinence with loop and thiazide diuretics were not statistically significant. Limitations for our study included unknown dose, adherence and indications for the diuretics, concomitant medication usage, and a small sample size (n=91). Additional research is required to compare urinary incontinence in individuals with abnormal CrCl taking a loop or thiazide diuretic.

Effect of Health Insurance on Achieving LDL Goals for Secondary Prevention of Cardiovascular Events

Purpose:

Dyslipidemia and calculated low-density lipoprotein (LDL-C) control is essential for preventing secondary cardiovascular events.1,2,3 There is a demonstrated relationship between absolute changes in LDL-C levels and an increased risk of secondary events2,3. Access to health insurance is a suspected factor for improved management of LDL-C levels4,5. The purpose of this study is to evaluate the relationship between those with and without health insurance reaching target LDL-C levels for secondary prevention.

Methods:

This cross-sectional study utilizes 2017-2018 NHANES data to examine LDL-C control among secondary prevention patients. Patients were included based on answering “yes” for a previous stroke or MI. The study outcome was defined as an LDL-C>100 mg/dL as calculated by the Friedewald formula6. The study exposure was a lack of current health insurance coverage as reported by the participant. Unadjusted and adjusted odds were calculated using a binary logistic regression model. The cutoff for statistical significance is a p <0.05. All statistical analyses were conducted with IBM SPSS.

Results:

The characteristics between the populations are evenly distributed in all characteristics except age, with a median age of 60 and 68. There is a 4.336 (95% CI; 1.628, 11.552) increase in odds of having an LDL-C>100 mg/dL for uninsured patients vs insured patients after a primary MI or stroke (p=0.003).

Conclusions:

The results of this study indicate a statistically significant difference in uncontrolled LDL-C levels for those uninsured compared to those that have health insurance. Some limitations of our study are insurance status and cardiovascular event history both being self-reported, and our uninsured population is significantly smaller compared to insured. This study suggests the importance of insurance in achieving treatment goals as a modifiable risk factor for clinicians and patients to consider.

Association of Asthma Severity in Patients Using Inhaled Recreational Drugs

Barrios

Purpose: Given the persistent rise of recreational drug use among the American population, the association with the severity of asthma remains uncertain. Some of these recreational drugs can be used via inhalation, such as marijuana, cocaine, and methamphetamine. The objective of this research is to assess the association between inhaled recreational drug use and the prevalence of asthma exacerbations.

Methods:

Using data from the 2017-2018 National Health and Nutrition Examination Survey, a multivariable logistic regression was performed to compare the exposure and outcome. The exposure was use of inhaled recreational drugs, including marijuana, cocaine, and methamphetamine. The outcome was the presence of asthma attacks in the past year. The inclusion criteria consist of patients aged 18-40 years old with current asthma who answered the screening questions regarding marijuana and cocaine/methamphetamine use. The exclusion criteria included patients below 18 and above 40 years-old who do not have current asthma and did not answer all relevant survey questions. The covariates included age, gender, race/ethnicity, eosinophil count, smoking status, education level in adults over 20 years old, and chronic bronchitis status.

Results:

A total of 146 participants met the inclusion criteria, with 83 reporting recreational drug use and 63 reporting no recreational drug use. There were no significant differences between the evaluated clinical characteristics among the study populations. The incidence of asthma attacks in participants who reported recreational drug use was 57.8%, versus 30.2% in those not using recreational drugs. The logistic regression results show a significant association between inhaled recreational drug use and asthma attacks in the past year (P = 0.050) when adjusting for multiple covariates.

Conclusion:

Inhaled recreational drug use was shown to increase asthma attacks in patients aged 18-40 years old, however, more studies are needed to prove a causal relationship between recreational drug use and asthma severity.

Prevalence of Anemia of Chronic Disease in patients with Chronic Kidney Disease.

Amanda Blais PharmD. Candidate, Kathryn McGee PharmD. Candidate, Mackenzie Plouffe

Purpose:

Patients with chronic kidney disease (CKD) may develop anemia due to decreased renal production of erythropoietin as a result of impaired kidney function. The purpose of this study was to analyze the relationship between serum creatinine level and the prevalence of anemia among patients living with CKD.

Methods: Cross sectional data was taken from the National Health and Nutrition Examination Survey (NHANES) to select participants, according to calculated estimated Glomerular Filtration Rate (eGFR), with an eGFR less than or equal to 60 milliliters per minute. Participants were stratified into three SCr subgroups, and coded according to baseline hemoglobin levels. Analysis of anemia prevalence was assessed in each subgroup using an adjusted logistic regression.

Results: Four hundred and forty one participants met inclusion and exclusion criteria. Exposure groups differed for participants' median age, gender, and prevalence of diabetes. Exposure groups were similar for participant’s race and prevalence of thyroid disorder. The study found prevalence of anemia increased among participants with SCr greater than 1.3 mg/dL, when compared to participants with SCr less than or equal to 1.3 mg/dL.

Conclusions: The study findings support an increased prevalence of anemia among CKD patients with higher serum creatinine values. Limitations of the study include limited generalizability because patients without self reported eGFR values were excluded from the population. Reporting bias may also reduce the study’s validity. The study used cross sectional data, limiting the ability to identify a temporal relationship. These results may be used to stimulate further research to understand a causal relationship between anemia prevalence and serum creatinine values.