Journal of Pharmacy Technology

To report a case of tigecycline-induced acute pancreatitis.

A 50-year-old African American man with spinal cord injury was hospitalized on 2 occasions for recurrence of an infected pressure ulcer requiring systemic antibiotic therapy. Bone and tissue cultures from his initial hospitalization grew multidrug resistant (MDR) Acinetobacter baumanii sensitive to tigecycline. He was treated with intravenous tigecycline on these 2 occasions (50-mg infusions every 12 hours), each of which resulted in significant elevation in serum amylase (to 615 U/L and 715 U/L) and lipase (to 325 U/L and 616 U/L) levels. On each occasion, the pancreatic enzymes became normal after discontinuing tigecycline.

Tigecycline is the first FDA-approved drug in the class of antibiotics called glycylcyclines, which are developed from tetracyclines to afford broad coverage against certain resistant gram-positive and gramnegative bacteria. It is recommended for patients at least 18 years of age for treatment of complicated intraabdominal infections, community-acquired bacterial pneumonia and complicated skin and skin structure infections caused by susceptible organisms. Tigecycline-induced pancreatitis is a rare adverse event. Review of the literature yielded only 6 prior documented cases (5 adult and 1 pediatric cases). Although the pediatric case demonstrated rechallenge, the patient concurrently received other antibiotics that are known to cause pancreatitis.

This is the first report, to our knowledge, of pancreatitis associated with monotherapy with tigecycline, and this relationship was confirmed upon rechallenging our patient with tigecycline. An objective causality assessment revealed that the adverse-drug-associated event was definite.

To report a case of neutropenia in a critically ill trauma patient who was receiving quetiapine for hyperactive delirium.

A 30-year-old white female was admitted to the neurosurgical intensive care unit following a motor vehicle crash. During her recovery in the intensive care unit, she received quetiapine for hyperactive delirium. The patient was initially started on quetiapine 50 mg/day, which was eventually increased to 100 mg/day. Her white blood cell count and neutrophil count were both noted to be decreasing, eventually reaching a nadir of 2.29 × 10⁹/L and 0.89 × 10⁹/L, respectively. Quetiapine was discontinued and her white blood cell count and neutrophil count returned to normal.

Quetiapine-induced neutropenia has rarely been reported. A MEDLINE search (1991-August 2012) revealed 12 case reports; however, in none of them had neutropenia occurred in critically ill patients. The available case reports reveal a wide variety of doses and durations of treatment with quetiapine-associated neutropenia. A definite mechanism for quetiapine-induced neutropenia is unknown. Quetiapine is structurally related to clozapine, known to cause neutropenia, and it may share a similar mechanism. The Naranjo probability scale revealed possible neutropenia associated with quetiapine.

With the increased use of quetiapine for hyperactive delirium in intensive care unit patients, health care professionals should be cognizant of the potential for quetiapine to induce neutropenia.

Xerostomia (dry mouth) is a common adverse effect of many medications and can severely diminish quality of life for older adults.

To assess the effectiveness of 3 categories of interventions used to manage drug-induced xerostomia and xerostomia secondary to Sjögren syndrome and radiation treatment for head and neck cancer in older adults: saliva substitutes, saliva stimulants, and topical fluoride.

The Cochrane Library, PubMed, EMBASE (to July 2009) and CINAHL (to February 2010) were searched for randomized or quasi-randomized studies involving older adults with drug- or radiation-induced xerostomia or Sjögren syndrome.

An updating search focusing on systematic reviews (to June 2012) was conducted prior to publication. Outcomes included perceived dryness of the mouth, reduced sialometry, or increased root caries. Duplicate study selection and data extraction were conducted. Risk of bias was assessed. A random effects meta-analysis was employed.

Four studies of saliva substitutes (N = 116), 3 studies of saliva stimulants (N = 361), and 1 of fluoride treatment (N = 334) met selection criteria. Saliva substitutes were more effective than other treatments at improving perceived dryness of the mouth as determined on a 10-point visual analog scale (weighted mean difference [WMD] −1.91 [95% CI −2.54 to −1.29]) but less effective than placebo (WMD 0.26 [95% CI 0.51–1.02]). Parasympathetic stimulants were more effective than placebo in improving oral dryness (OR = 0.37 [95% CI 0.19–0.72]). Due to lack of data, quantitative synthesis of results for topical fluoride was not possible.

There is evidence to suggest that saliva substitutes improve symptoms but the clinical significance is minimal. The evidence more strongly supports the effect of saliva stimulants, although the quality of evidence is poor and adverse effects from these medications cannot be overlooked. Evidence demonstrating efficacy of topical fluoride in disease prevention was inconclusive. Addressing underlying causes of xerostomia, including drug choices, may help mitigate the burden of illness and effects on quality of life.

To provide an evidence-based broad review of the pharmacologic management of orthostatic hypotension (OH) in the patient with diabetes.

A search of PubMed, MD Consult, International Pharmaceutical Abstracts, and the Cochrane Register of Clinical Trials and Systematic Reviews was performed using the key words diabetes, autonomic neuropathy, orthostatic hypotension, midodrine, fludrocortisone, pyridostigmine, xamoterol, octreotide, pindolol, dihydroergotamine, erythropoietin, clonidine, acarbose, desmopressin, and droxidopa. Literature published between 1976 and August 2012 was included.

All articles in English and studies in humans including clinical trials, meta-analyses, practice guidelines, randomized controlled trials, and review articles were identified and evaluated. Studies not including patients with diabetes were excluded. The selection of materials was focused on those that would aid the pharmacist in caring for patients with orthostatic hypotension resulting from diabetic neuropathy.

Definitive guidelines on the pharmacologic management of OH in the patient with diabetes are not available and recommendations must be assessed from available evidence-based sources. Ten trials of medications used in the patient with diabetes were assessed for efficacy and safety. From these trials, evidence-based therapy options were recommended. If nonpharmacologic measures are insufficient in ameliorating symptoms, fludrocortisone or midodrine should be considered as first-line agents in the absence of contraindications. Pyridostigmine, octreotide, or recombinant erythropoietin may be useful as adjunct or alternative agents. Combination therapy may be considered, based on coexisting conditions or response. When recommending both nonpharmacologic and pharmacologic therapy, careful attention should be paid to comorbid conditions such as congestive heart failure, supine hypertension, and kidney disease.

There is insufficient evidence to recommend the routine use of medications other than the first-line agents fludrocortisone or midodrine in this patient population. Further trials with existing and new therapeutic options in patients with diabetes are warranted.

The American Diabetes Association (ADA) has emphasized the need for patients to receive diabetes self-management education (DSME) as a standard of care. Various DSME models have been described, including individual or group sessions. There is no preferred method reported in the literature.

To determine the effect of group DSME classes on patients' hemoglobin A_1c (A1C), blood pressure (BP), and low-density lipoprotein cholesterol (LDL-C). Patient satisfaction was also assessed.

Pharmacists offered 4 group education classes to patients over the course of 1 year using the ADA Diabetes Conversation Maps. Patients were encouraged to attend all sessions to cover the entire curriculum; however, many attended only 1 class. Patient A1C, BP, and LDL-C were monitored before the first class and after the last class attended. The Wilcoxon signed-rank test and descriptive statistics were used for data analysis.

Thirty-two patients attended at least 1 of the group classes, and 9 returned for more than 1 class. Baseline characteristics included a mean age of 58 years, baseline A1C of 9.4%, systolic BP of 140.6 mm Hg, diastolic BP of 77.2 mm Hg, and LDL-C of 99.1 mg/dL. An average decrease of 1.1% in A1C, 5.1 mm Hg in systolic BP, 1.9 mm Hg in diastolic BP, and 4.6 mg/dL in LDL-C was seen from baseline after class participation. For patients who attended more than 1 class, a statistically significant decrease of 3.6% occurred in A1C (p < 0.05). The majority of patients (84%) reported greater satisfaction with the group DSME as compared with individual diabetes education.

Data from this study support offering group DSME classes as a method of patient education at a family medicine clinic.

Approximately half of American adults have trouble understanding and acting on health information. United States Pharmacopeia (USP) pictograms are standardized graphic images that help convey medication instructions, precautions, and/or warnings to patients and consumers. No published literature exists regarding USP pictogram-based prescription instructions for adults in the US.

To gauge the perceived effect of USP pictograms included within patient information handouts in community pharmacy settings in the US.

Two sets of patient information handouts were made for each of 2 community pharmacies' self-reported top 20 medications: one containing USP pictogram-based patient information and the other containing the same text without pictograms. Over a 6-week period, patients filling or refilling a prescription for one of the 20 medications were offered counseling using either a pictogram- or non-pictogram-based handout, selected at random. A patient-administered survey assessed 4 criteria of the handout received: user-friendliness, long-term comprehension, likelihood of referring to the handout in the future, and effectiveness.

The addition of pictograms significantly increased only the likelihood of the patient referring to the handout in the future.

Results suggest a potential role for USP pictograms that should be evaluated on a larger scale in the future.