Home Medication Research Articles

8269 Euglycemic Diabetic Ketoacidosis Secondary to Rapid Weight Loss in a Patient on Dapagliflozin

Abstract Disclosure: A. Sridhar: None. A. Iqbal: None. A. Prabha Kumar: None. F. Haider: None. M. Babic: None. Background: Euglycemic DKA (eDKA) is a potentially life-threatening complication in patients taking SGLT 2 inhibitors (SGLT2i). Common precipitating factors include strenuous exercise, carbohydrate restriction, starvation, and alcohol use. Clinical case: The patient is a 71-year-old female with past medical history of Type 2 diabetes mellitus (DM), gastro-esophageal reflux disease, hypertension, hyperlipidemia, coronary artery disease and chronic pain syndrome. She presented with complaints of nausea, vomiting, reduced appetite and generalized weakness for the past 4 days. She also reported an intentional weight loss of 35 pounds in the last 6 weeks achieved with daily exercise and a carbohydrate restricted diet. She had been taking Dapagliflozin-Metformin 5-1000 mg twice daily and pioglitazone 30 mg once daily for 2 years and Ozempic subcutaneous injection 1 mg weekly for 6 months. Physical examination in the ED showed normal vital signs, dry mucous membranes, and trace bilateral lower extremity edema. Blood work was significant for venous blood gas pH 7.24, bicarbonate 9 mmol/L, anion gap 30 mmol/L, blood glucose 94 mg/dL, HbA1c 5.8 % and WBC 13.2 K/uL. Urinalysis was positive for glucose and ketones. The patient was admitted for management of eDKA and was started on intravenous 10% dextrose infusion and insulin infusion. Endocrinology was consulted and they recommended following DKA protocol and stopping Dapagliflozin at discharge. She was maintained on insulin infusion for 48 hours after which her anion gap normalized, and she was transitioned to subcutaneous insulin with Lantus 8 units and sliding scale insulin. During this time the patient’s symptoms resolved, and she was able to tolerate oral diet. She eventually resumed her home medications with oral Metformin 1000 mg twice daily and pioglitazone 30 mg once daily. Dapagliflozin and Ozempic were discontinued at discharge. Strenuous exercise and carbohydrate restriction which caused rapid weight loss, were likely the triggers for eDKA in our patient. A diabetes educator was involved at discharge and the patient was counseled to avoid possible triggers and identify warning signs and symptoms in the future. The patient was discharged with a follow up appointment with her Endocrinologist. Conclusion: High index of clinical suspicion is important to promptly diagnose eDKA in patients taking SGLT2i. Patient education on avoiding precipitating factors and early recognition of signs and symptoms is necessary to reduce mortality. Presentation: 6/3/2024

8243 Euglycemic Diabetic Ketoacidosis Unveiled: Delayed Presentation and Complications of SGLT-2 Inhibitor Therapy in a Multimorbid Patient - A Case Report

Abstract Disclosure: T. Amin: None. A.K. Bala: None. M.A. Jones: None. M.S. Akula: None. K. Chalasani: None. M. Patel: None. J. Cheng: None. Introduction: Normal serum glucose levels (<200 mg/dL) in euglycemic diabetic ketoacidosis (EDKA) can complicate the typical clinical presentation of diabetic ketoacidosis (DKA), posing a diagnostic challenge. SGLT-2 inhibitors, a class of antihyperglycemic drugs, have been rarely but significantly associated with EDKA. These inhibitors enhance renal glucose clearance by preventing glucose reabsorption via sodium-glucose cotransport. The increased renal clearance may contribute to the euglycemic picture, potentially leading to an underestimation of required insulin dosage, thereby precipitating ketoacidosis in EDKA. Although the mechanisms of EDKA are not fully understood, the association with SGLT-2 inhibitors is becoming increasingly evident. Case A 53-year-old male with a medical history of type 2 Diabetes Mellitus, coronary artery disease, chronic kidney disease, hyperlipidemia, was admitted to the trauma bay after a fall. Medications included empagliflozin, metformin, aspirin, amlodipine, spironolactone, and carvedilol. Upon presentation, he had a brief loss of consciousness, complained of headache and chest pain, and was found to have an epidural hematoma with regional brain compression on the CT head. Admission labs showed a blood glucose level of 172, an unremarkable anion gap, and normal renal and liver function tests. Due to traumatic brain injury, he was admitted to the ICU for neurological monitoring. Despite remaining neurologically stable, he developed hypoxia, necessitating intubation. After successful extubation, he exhibited worsening metabolic acidosis on the fourth day, with an elevated anion gap of 22 and a blood glucose level of 174. Arterial blood gas analysis revealed a pH of 7.3 (and elevated beta-hydroxybutyrate (>4), while lactic acid levels remained normal. Urine analysis showed elevated blood glucose (>1000) and ketones (>40). Home medications, metformin, and empagliflozin were appropriately withheld, but euglycemic DKA attributed to empagliflozin was diagnosed. Treatment included intravenous fluid resuscitation and insulin infusion, leading to resolution of acidosis and improved mentation within 24 hours. Conclusion: EDKA is a diagnosis of exclusion often overlooked in ICU patients due to diverse causes of high-anion gap metabolic acidosis. Typical cases occur while the patient is using the drug, often associated with triggers like illness, alcohol use, surgery, or starvation. SGLT2 inhibitors, such as empagliflozin, with a half-life of 12.4 hours, are expected to clear the bloodstream in about 48 hours, yet this case suggests an association with EDKA both during use and after drug cessation. This delayed presentation highlights additional risk considerations associated with SGLT2 inhibitors, guiding future clinical diagnoses of EDKA even several days post discontinuation. Presentation: 6/3/2024

12262 Pheochromocytoma Masquerading As An Acute Myocardial Infarction And Takotsubo Cardiomyopathy In A Hispanic Woman: A Case Report

Abstract Disclosure: A. Hoskote: None. J. Seidenberg: None. V. Gupta: None. Pheochromocytoma is a rare neuroendocrine tumor (<1 per 100,000 person-years) that occurs sporadically or due to mutations. While most patients do not have the classic headache, sweating and tachycardia, about 50% have paroxysmal hypertension and 90% have headaches. We present a rare case of pheochromocytoma masquerading as myocardial infarction (MI) and cardiomyopathy. A 67-year-old Hispanic female with history of hypertension and uncontrolled Type 2 DM, presented to the ER for chest pain and diaphoresis. Home medications were metformin, sitagliptin, lisinopril, simvastatin and aspirin. EKG showed non-specific ST elevations in chest leads without STEMI, and labs revealed a dynamic troponin and hemoglobin A1C of 13.6%. CT angiography ruled out pulmonary embolism. A left heart catheterization and echocardiogram revealed non obstructive coronary artery disease (CAD), a left ventricular ejection fraction of 25%, apical ballooning and a laminar thrombus. She was diagnosed with acute myocardial infarction and Takotsubo cardiomyopathy and discharged on metoprolol and apixaban. During our evaluation 7 months later, we noted several ER and hospital admissions for symptomatic hypertensive emergency with a pattern of labile blood pressures and on review of initial CT scan, a sequentially growing left adrenal mass (3.9cm 29HU) was present. A careful history using Spanish interpretation revealed episodic headaches, diaphoresis and palpitations. Subsequently, on two separate occasions, plasma normetanephrine was 2006 pg/mL (ULN<148 pg/mL) and urine normetanephrine was 12516 mcg/g cr (ULN <524 mcg/g cr). Prazosin was prescribed with stabilization of hypertension. An adrenalectomy is now scheduled. Symptoms of pheochromocytoma and paraganglioma (PPGs) are caused by hypersecretion of one or combinations of catecholamines: norepinephrine, epinephrine and dopamine. In one study 27% were discovered due to symptoms while 61% were found incidentally. PPGs occur in up to 1:500 patients with arterial hypertension and can also be a secondary cause of diabetes. MI and acute or chronic cardiomyopathy are rare presenting features of PPGs. Takotsubo cardiomyopathy is the most common phenotype. In one acute MI study, Hispanic women were significantly more likely to receive delayed care as compared to non-Hispanic women, due to misinterpretation of symptoms by patients and providers. A meticulous history with formal interpretation in patients with limited English proficiency can lead to prompt diagnosis of this surgically curable cause of hypertension. Pheochromocytomas rarely present as acute myocardial infarction and stress cardiomyopathy. A high suspicion for PPGs must be maintained in patients with labile hypertension, cardiomyopathy and an incidental adrenal mass. History should be carefully revisited especially in patients with limited English proficiency. Presentation: 6/3/2024

8278 Myxedema Coma With COVID-19 Infection

Abstract Disclosure: R. Kalas: None. V. Manohar: None. N.S. Bapat: None. Y. Kim: None. Myxedema coma is a rare medical emergency that occurs in severe hypothyroidism with a mortality rate reaching 60%. The hallmarks include depressed mental status and hypothermia, but hypotension, hyponatremia, bradycardia, and hypoventilation can also occur. This complication can occur in patients with a longstanding history of severe hypothyroidism especially when precipitated by an acute event such as infection, myocardial infarction, or surgery. Prompt recognition and treatment of the condition is important to prevent fatal outcomes. We present a case of myxedema coma in the setting of COVID-19 infection and nonadherence to medication. A 91-year-old woman with history of hypothyroidism, hypertension, coronary artery disease, cardiomyopathy, and chronic obstructive pulmonary disease presented with dyspnea. Her home medications included levothyroxine 75 mcg daily, which she reported not taking for at least 3 weeks. Vital signs revealed a normal heart rate and blood pressure of 84 beats/min and 137/78 mmHg, but the patient was hypothermic to 35.7 °C. On exam, she was somnolent. Labs were notable for markedly elevated TSH level of 111 (0.380 - 4.700 uIU/mL), low free T4 level of 0.57 (0.93 - 1.70 ng/dL), random cortisol level of 25.5 (6.2-18.4 ug/dL), and positive SARS-COV-2 PCR test. Chest x-ray revealed bilateral lower lung parenchymal consolidations and arterial blood gas revealed a pH of 7.29 and pCO2 of 52.5 (35-45 mm Hg), indicating hypercapnia. She was treated for COVID pneumonia and given concern for COVID induced myxedema coma she was given IV levothyroxine 100 mcg for 2 days, after which the patient’s hypothermia and somnolence improved, with an improved repeat free T4 level 0.87 ng/dL. She was subsequently transitioned to oral levothyroxine 112 mcg daily and discharged after improvement of her COVID symptoms. Myxedema coma is a rare complication of decompensated hypothyroidism, frequently triggered by an infection. Thyroid hormone plays an important role in regulating both the innate and adaptive immune systems. As a result, individuals with hypothyroidism are at increased risk of acquiring infections, which can further lead to myxedema coma. COVID-19 infection has been associated with thyrotoxicosis, thyroiditis and hypothyroidism. Given the associated high mortality rate, regardless of the underlying precipitant, prompt diagnosis and early administration of thyroid hormone replacement therapy is crucial to improve outcomes. Presentation: 6/3/2024

7928 A "PTH-Mediated" Hypercalcemia Of Malignancy

Abstract Disclosure: N. Sekhon: None. R.J. Bingham: None. Background: We present a challenging diagnostic case of a 73-year-old female with PTH-mediated hypercalcemia in the presence of new metastatic uterine cancer. Case: A 73-year-old female with a past medical history of hypertension and abdominal aortic aneurysm was seen in the hospital for hypercalcemia. She endorsed constipation, fatigue, and generalized weakness for the past few weeks. This was the second hospitalization related to hypercalcemia over the period of 10 days. During the previous hospitalization, her admission calcium was 17 mg/dL and was treated with IV fluids, calcitonin, and zoledronic acid. There was a history of intentional weight loss of about 30-40 lbs in the last 3 months by reducing carbohydrate intake. The patient had a 40-pack years of smoking history. There was no family history of calcium disorders or cancers. Home medications included amlodipine 10 mg QD, docusate sodium 100 mg BID, senna 1 tab QHS, and Vit D 5000 U QD. On physical examination, she was hemodynamically stable but appeared confused and lethargic. The rest of the examination was unremarkable. Laboratory results were remarkable for hypercalcemia (Ca: 13.3 mg/dL), hypophosphatemia (Phosphorus: 2.3 mg/dL), and elevated PTH of 418.3 pg/mL (Ref. Range: 18.4-80.1 pg/mL). CT abdomen/ pelvis revealed innumerable ill-defined hypodense lesions throughout the liver concerning metastatic disease and a 5 cm mass in the uterine fundus. The patient was worked up with the view of hypercalcemia related to malignancy. However, PTHrP (PTH-related peptide) came back normal, which was checked twice during both hospitalizations. Liver biopsy showed metastatic high-grade carcinoma highly suspicious for GYN malignancy with negative PTH staining. Imaging studies for localization including CT soft tissue neck and CT 4D parathyroid with and without contrast failed to show any parathyroid lesions. Endometrial biopsy obtained during subsequent hospitalization showed high-grade adenocarcinoma with focal squamous differentiation. Immunohistochemical staining identified scattered positivity for PTH. The patient was managed as per hypercalcemia of malignancy guidelines with IV fluids and denosumab. Discussion: Hypercalcemia of malignancy due to ectopic PTH secretion has been reported in < 1% of cases. Only two endometrial cancer cases with ectopic PTH have been reported in the literature. PTH-mediated hypercalcemia is seen in primary hyperparathyroidism, parathyroid cancers, or ectopic PTH. In all cases of hypercalcemia of malignancy, primary hyperparathyroidism should be ruled out in the presence of elevated PTH. Diagnosing ectopic PTH secretion by tumor can be challenging due to constant changes in cells with metastasis. Conclusion: This is a rare case of endometrial cancer with liver metastasis and ectopic PTH secretion by primary tumor leading to recurrent hospitalizations related to hypercalcemia. Presentation: 6/2/2024

8132 Prolonged Refractory Hypoglycemia For Seven Days After Discontinuation Of Neutral Protamine Hagedorn (NPH) Insulin And Injectable Semaglutide

Abstract Disclosure: A. Musleh: None. M.T. Rauf: None. E. Afroze: None. S. Al-Bacha: None. A 75-year-old male with Type 2 Diabetes was brought to the emergency department (ED) by emergency medical services (EMS) due to altered mentation. The patient’s wife found him unresponsive with seizure-like activity. EMS was called to the scene and obtained a capillary blood glucose reading of 31 mg/dL. Despite initial treatment with 50% dextrose the patient’s capillary blood glucose came down to 21 mg/dL in the ED and was confirmed by venous glucose. Workup including Computed Tomography (CT) imaging was inconsistent with a cerebrovascular accident. Given refractory hypoglycemia and delirium, the patient was started on a dextrose 10% infusion at 150 milliliters per hour. He was admitted to the intensive care unit for closer monitoring. His wife states that the patient had a few episodes of mild hypoglycemia overnight for the past several weeks, which improved after eating. His home medications included NPH insulin 46 units twice daily, empagliflozin 25 mg once daily, and injectable semaglutide 2 mg once weekly. The last dose of NPH insulin was the night before the presentation and the last dose of semaglutide was 5 days prior to admission. Serum creatinine levels were stable at 1.3-1.5 mg/dL throughout the hospitalization, which was below his baseline creatinine of 1.7 mg/dL. Laboratory results were as follows: hemoglobin A1c 5.9%, c-peptide level was 0.3 ng/mL (normal range 0.8-3.9 ng/mL) with a glucose of 68 mg/dL (normal range 70-100 mg/dL), insulin 203.8 mcIU/mL (normal range less than 24 mcIU/mL), proinsulin 3.2 pmol/L (normal range less than or equal to 8 pmol/L), beta-hydroxybutyrate 0.06 mmol/L (normal range 0.02-0.27), cortisol 66.6 mcg/dL (normal range 6.7-22.6 mcg/dL), insulin-like growth factor 1 123 ng/mL (normal range 53-222), and hypoglycemic agent panel was negative. On ICU Day 2, his mentation improved, he was allowed to eat but continued to require dextrose infusion to prevent hypoglycemia. Repeat fasting insulin levels even four days from prior showed an incremental decrease to 59.4 mcIU/mL with a glucose of 77 mg/dL. It took 7 days before the patient was able to maintain glucose above 70 mg/dL off of dextrose infusion. After which he had hyperglycemia requiring gradual reintroduction of his diabetes medicines other than insulin. It is rare to see such prolonged refractory hypoglycemia from an exogenous source of insulin as exhibited in this case. Notably, the patient was on semaglutide and had stable chronic kidney disease without acute kidney injury. Although multiple mechanisms explain the prolonged insulin duration of action in kidney disease, the effects of semaglutide on insulin action are unknown. Presentation: 6/3/2024

6768 A Rare Presentation of Primary Adrenal Insufficiency with Hypertension & Hypokalemia

Abstract Disclosure: A.M. San Hernandez: None. R. Alshantti: None. G. Espinoza Mercado: None. J.L. San Hernandez: None. Introduction: Adrenal Insufficiency is caused by the failure of the adrenal cortex to produce glucocorticoids +/- mineralocorticoids. This can be due to a defect in the adrenal cortex, or in the hypothalamic pituitary axis. The clinical manifestations are usually non-specific, ranging from mild vague symptoms to life threatening crisis. Therefore, diagnosis requires a high level of suspicion by providers. Unusual presentations of primary adrenal insufficiency (PAI) with hypertension and hypokalemia have been rarely described in the literature. We present a rare case of PAI with hypertension and hypokalemia. Case Presentation: A 68 years old female with a medical history of rheumatoid arthritis, hypothyroidism on Levothyroxine, chronic transaminitis, and bicytopenia presented to the hospital with a 6 weeks history of generalized weakness, loss of appetite, weight loss, and dizziness. Patient denied any diuretic or steroid use within the last 2 years. On arrival, she was afebrile, hypertensive (168/84mmHg), with normal oxygenation and pulse. Physical examination was unremarkable with normal volume status. Initial laboratory results showed low sodium 116 mEq/L, low serum osmolality 247 MEQ/kg, normal potassium 3.6 mEq/L, Creatinine 0.3 mg/dL & BUN 9 mg/dL. She was initially started on IVF normal saline. Further workup revealed normal TSH & FT4 levels. Urine study showed urine osmolality (477 MOSM/KG), & urine sodium (127 mEq/L). Given these findings, SIADH was suspected and fluid restriction was started. Sodium level continued to be low with minimal improvement to 120 mEq/L, potassium levels also dropped (3.3-3.2 mEq/L), requiring daily replacement. BP remained elevated ranging from 150s to 160s systolic and 80s to 90s diastolic. Hypertension was controlled with her home medication Amlodipine. Although atypical presentation with hypertension & hypokalemia, the diagnosis of adrenal insufficiency was considered. Laboratory evaluation showed low morning cortisol 5.2 ug/dL, with album level 3.5 g/dL. Cosyntropin stimulation test showed 1.3 ug/dL (at baseline), 9.9 (30 min post administration), and 14.4 (1 hour post administration); results confirming PAI. ACTH, Renin, Aldosterone, & DHEAS levels were normal. CT adrenal was normal. Patient was started on hydrocortisone; some of her symptoms & Na level improved. Further investigation of the etiology of PAI and possible hyperaldosteronism is pending outpatient follow up. Conclusion: Adrenal insufficiency is a life threatening condition with serious consequences if diagnosis is missed. It manifests by a wide spectrum of symptoms and signs, some can be masked by the presence of other comorbid conditions leading to atypical presentations. Our case highlights the importance of maintaining a high level of suspicion of adrenal insufficiency in patients with atypical presentation, including those with hypertension & hypokalemia. Presentation: 6/3/2024

Profiles of Home Medication Use in Patients on Dialysis Globally

Profiles of Home Medication Use in Patients on Dialysis Globally

In-Home Intravenous Dexmedetomidine Infusion for Treatment of Dystonia: A Pediatric Case Report

The off-label use of an intravenous dexmedetomidine infusion is an option for refractory symptoms in pediatric palliative care with a few published cases of in-home use, most limited to end-of-life care. After an intrathecal baclofen pump malfunction with meningitis and medication withdrawal, a 17-year-old adolescent with quadriparetic cerebral palsy and paroxysmal autonomic instability experienced relief of refractory pain and dystonia with an in-home intravenous dexmedetomidine infusion. His interdisciplinary care team collaborated to establish safety measures and adjust his home medication regimen to further improve quality of life well before his end of life.

Caring for patients with diabetes in the outpatient surgical setting: current recommendations and controversies.

Perioperative outpatient (ambulatory) care of the adult patient with diabetes requires unique considerations that vary from the inpatient setting. This review highlights specific pre, intra, and postoperative care steps for patients with diabetes undergoing ambulatory surgery, summarizing recent clinical trials, expert reviews, and emerging evidence. There is a paucity of evidence examining optimal diabetes management in the outpatient setting. Currently, there are limited studies regarding preoperative management of oral hypoglycemic agents, home insulin, and carbohydrate-containing beverages. Future research needs to specifically examine chronic blood glucose control, day of surgery targets, effective home medication management and the risk of perioperative hyperglycemia in ambulatory surgery. Education, protocols and resources to support the care of perioperative patients in the outpatient setting will aid providers on the day of surgery and provide optimal diabetes care leading up to surgery.

The Impact of Home Medication Management Practices on Medication Adherence.

Medication adherence is a vexing challenge, with over 50% of US adults not adhering to their prescribed medication regimen. Most medications are self-administered by patients at home, requiring them to independently develop and manage their own medication routines. By understanding these home-based practices, such as where patients store their medications and how different storage locations impact adherence, we can develop targeted interventions to improve adherence rates. Our goal was to identify and categorize self-reported home medication management practices and determine which practices are associated with self-reported medication adherence. From the 1673 total survey respondents we learned that the most common places people store their medications at home are nightstand drawers (28%), on top of nightstands (27%), kitchen cabinets (22%), and bathroom medicine cabinets (20%). Kitchen cabinets and bathroom vanities were significantly associated with increased odds of having ever forgotten to take a medication. On the other hand, desks, dining room tables, and the inside of nightstand drawers were associated with the greatest statistically significant decrease in odds of having ever forgotten to take a medication. Almost all (96%) respondents were receptive to receiving guidance from healthcare providers on how to store medications. Patients are largely responsible for creating their own home medication management practices, including deciding where to store their medication at home. Understanding which home storage locations are associated with medication adherence can lead to innovative approaches to improve adherence, including personalized guidance to patients from their healthcare providers for patients.

A surgical preadmission pharmacist service in a tertiary paediatric hospital: a pilot study

AbstractBackgroundPharmacist surgical preadmission review is common in adult healthcare settings, however there is little evidence of this practice in the paediatric setting. This research describes a pilot surgical preadmission pharmacist service in a paediatric hospital.AimTo evaluate the impact of a surgical preadmission pharmacist service on patient flow and the quality of medication management.MethodA retrospective review (2 months) was conducted to compare an intervention group (1 May 2019–30 June 2019) to historical baseline (1 October 2018–30 November 2018). Children and adolescents (aged 0–18 years) presenting for elective surgery and overnight admission were included. Relevant clinical data and timestamps were extracted from the electronic medical record. Multiple linear regression models were built to examine the difference in outcomes between the control and intervention groups. This project was exempt due to the local policy requirements that constitute research by the Queensland Children's Hospital Human Research Ethics Committee (Reference no: LNR/19/QCHQ/53406). The justification for this exemption was as follows: the study presented no foreseeable risk of patient harm as it involved evaluation of an established standard of clinical care and involved the use of existing collections of records that contain only non‐identifiable patient data.ResultsIn total, 135 patients were included in the baseline and 96 patients were included in the intervention group. The intervention group had statistically significant lower time to best possible medication history (BPMH) by 47.57 h (95% confidence interval [CI] −53.25 to −41.89, p < 0.001). Time to prescription of home medications was significantly reduced in the intervention group by 5.26 h (95% CI −10.45 to −0.08, p = 0.05). There was no difference in proportion of patients with home medications omitted (71–62%, p = 0.38) or requiring modification (14–12%, p = 0.58) between the two groups.ConclusionImplementation of a surgical preadmission pharmacist service in our paediatric hospital demonstrated earlier BPMH documentation and prescription of home medications, without negative effects on perioperative patient flow.

Knowledge and practices on home medication storage and disposal in Syria: a population-based, cross-sectional study

BackgroundMedications are commonly found in every household. In Syria, where healthcare infrastructure faces significant challenges, improper storage can lead to reduced medication efficacy and increased health risks. Additionally, inappropriate disposal practices pose serious environmental concerns, especially in a region already grappling with environmental degradation. This study aimed to evaluate the knowledge, and practices of Syrian individuals regarding the appropriate storage and disposal of home medications.MethodA cross-sectional study was conducted from September 22 to October 20, 2023, using an online survey distributed via social media apps (WhatsApp, Facebook, and Telegram) in Syria. The questionnaire, adapted from a similar study in Saudi Arabia, was translated to Arabic using the forward–backward translation technique. A convenience sampling technique was used. Inclusion criteria were participants over eighteen with expired or unused medications at home. Descriptive statistics, Chi-square tests, and binary logistic regression analysis were performed using SPSS version 27, with statistical significance defined as p < 0.05.ResultsA total of 2,217 responses were analyzed, with the majority of participants being female (79%) and aged between 21–30 years (56%). The study found that 90.7% of respondents dispose of expired medications in the garbage, while 95% keep medications in their original containers. Additionally, 30% consult pharmacists for storage instructions, and 64% read storage information on medication leaflets. Logistic regression analysis revealed that males were less likely to check expiration dates before use (OR: 0.58, 95% CI: 0.40–0.84) and periodically (OR: 0.68, 95% CI: 0.54–0.85). Participants aged 31–40 years were less likely to check expiration dates periodically (OR: 0.46, 95% CI: 0.31–0.68), while those with children under six years old were more likely to do so (OR: 1.29, 95% CI: 1.01–1.67). Males were also less likely to read storage instructions (OR: 0.61, 95% CI: 0.50–0.76) but more likely to ask pharmacists about them (OR: 1.26, 95% CI: 1.01–1.57). There was no significant difference in these practices between medical professionals and the general population.ConclusionThis study reveals gaps in the practices related to the storage and disposal of medications among the Syrian public. The findings suggest a need for targeted public education and awareness programs to improve these practices and reduce the associated health and environmental risks.

Hypertension knowledge and its associated factors among hypertensive patients in primary care settings in Central Vietnam: A cross-sectional study

Context: Hypertension is highly prevalent in Vietnam, yet the rate of controlled hypertension remains low. Knowledge about hypertension is linked to patient beliefs and medication adherence. However, there's limited data on hypertension knowledge among primary care patients in Vietnam. Aims: To evaluate the knowledge of hypertension among hypertensive patients in primary care settings in Central Vietnam and identify factors affecting their knowledge. Methods: A cross-sectional study was conducted, and a thorough examination was performed to assess hypertension knowledge and its related factors. Utilizing the Hypertension Knowledge Level Scale and Medication Adherence Report Scale, hypertension knowledge and medication adherence were evaluated. Additionally, demographic, clinical, lifestyle, and patient belief data were gathered. Statistical analyses and logistic regression models were applied to pinpoint key factors associated with hypertension knowledge. Results: In the study involving 761 participants (55.7% male), the average hypertension knowledge score was 15.0 (SD = 4.6), with only 45.3% demonstrating a high level of knowledge. Significant correlations were observed between hypertension knowledge and variables such as education level, ethnicity, home blood pressure monitoring, patient beliefs, and medication adherence. Logistic regression analysis indicated that higher education levels and belonging to the majority ethnicity were linked to enhanced hypertension knowledge. Notably, individuals with better hypertension knowledge tended to recognize the necessity of their prescribed medications. Conclusions: Hypertension knowledge among primary care patients in Central Vietnam is suboptimal, with approximately half having a high knowledge level. These findings emphasize the importance of hypertension knowledge in shaping patient beliefs, perceptions, and medication adherence. Tailored educational interventions are crucial, especially for those with lower education and minority backgrounds, to enhance hypertension management.

Temporal Effect of CYP3A4/5 Induction on Ticagrelor's Pharmacodynamic Effects: A Case Series.

Ticagrelor is contraindicated in combination with cytochrome P450 3A4 and 3A5 enzyme (CYP3A4/5) inducers due to increased clearance, causing diminished antiplatelet effects. The emergent nature of acute coronary syndromes (ACS) may preclude scrutinization of home medications before P2Y12 inhibitor administration. The purpose of this case series is to establish the temporal impact of CYP3A4/5 enzyme induction on ticagrelor's pharmacodynamic effect by utilizing VerifyNow platelet aggregation studies. This was a retrospective case series of three patients who were taking a CYP3A4/5-inducing medication and loaded with ticagrelor for ACS. The duration of ticagrelor's antiplatelet effect was dramatically shortened in the presence of background CYP3A4/5 induction. The offset of antiplatelet effect, defined by platelet reactivity units (PRU), was 10-24hours in the presence of CYP3A4/5 enzyme induction compared to the anticipated 36-48 hours. This was consistent across CYP3A4/5-inducing medications including carbamazepine, phenobarbital, and phenytoin. This study demonstrates rapid return of platelet function after a ticagrelor loading dose in the presence of CYP3A4/5-inducing medications. Monitoring of PRU every 6-12hours with subsequent loading with clopidogrel or prasugrel should be considered. Larger scale studies are warranted to confirm these results.

Medication Management Strategies to Support Medication Adherence: Interview Study With Older Adults.

Home medication management has been insufficiently studied, including the factors that impact the development and effectiveness of adherence strategies under both routine and anomalous circumstances. Older adults are a particularly important population to study due to the greater likelihood of taking medication in combination with the desire to "age in place." This interview study aims to understand how older adults develop medication management strategies, identify when and why such strategies succeed or fail, learn more about how older adults think about their medication, and explore interventions that increase medication adherence. This study used a qualitative, semistructured interview design to elicit older adults' experiences with home medication management. Overall, 22 participants aged ≥50 years taking 1 to 3 prescription medications were recruited and interviewed. Interview responses were recorded, and thematic, qualitative analysis was performed by reviewing recordings and identifying recurring patterns and themes. Responses were systematically coded, which not only facilitated the identification of these themes but also allowed us to quantify the prevalence of behaviors and perceptions, providing a robust understanding of medication management and medication adherence. Participants reported developing home medication management strategies on their own, with none of the participants receiving guidance from health care providers and 59% (13/22) of the participants using trial and error. The strategies developed by study participants were all unique and generally encompassed prescription medication and vitamins or supplements, with no demarcation between what was prescribed or recommended by a physician and what they selected independently. Participants thought about their medications by their chemical name (10/22, 45%), by the appearance of the pill (8/22, 36%), by the medication's purpose (2/22, 9%), or by the medication's generic name (2/22, 9%). Pill cases (17/22, 77%) were more popular than prescription bottles (5/22, 23%) for storage of daily medication. Most participants (19/22, 86%) stored their pill cases or prescription bottles in visible locations in the home, and those using pill cases varied in their refill routines. Participants used ≥2 routines or objects as triggers to take their medication. Nonadherence was associated with a disruption to their routine. Finally, only 14% (3/22) of the participants used a time-based reminder or alarm, and none of the participants used a medication adherence device or app. Participants in our study varied considerably in their home medication management strategies and developed unique routines to remember to take their medication as well as to refill their pill cases. To reduce trial and error in establishing a strategy, there are opportunities for physicians and pharmacists to provide adherence guidance to older adults. To minimize the impact of disruptions on adherence, there are opportunities to develop more durable strategies and to design aids to medication adherence that leverage established daily routines.

Predictive Factors of Peripheral Arterial Disease in Home Care Patients

Objective: The aim of the present study was to investigate the predictive factors of peripheral arterial disease (PAD) in home care patients. Materials and Methods: This descriptive study was conducted in Istanbul with 285 homebound patients who applied for the first time to receive services from the Home Health Care Unit of a tertiary hospital between 01.07.2014 and 01.12.2014. The patients having known PAD diagnosis were excluded. Sociodemographic characteristics, home dependency duration, chronic diseases, medications used and smoking status were recorded. Then, deformities in the patients' toenails, peripheral hair loss, foot wounds were recorded, and the patients' functional status and skinfold thickness were evaluated peripheral arterial disease was evaluated by ankle–brachial index (ABI). An ABI below 0.9 was considered indicative of PAD. A chi-square test, Mann–Whitney U test and a logistic regression analysis were used in the statistical analysis. Results: The mean age of the participants was 75.84±1.17 years (34% M; 65% F). Peripheral artery disease was detected in 16.8% (n=48) of the patients. Current or former smoking (β: 4.09), peripheral hair loss (β: 3.42), deformity of toenails (β: 3.02), and increased skinfold thickness (β: 1.124) were identified as predictors of PAD. Conclusion: The findings of the present study suggest that home healthcare providers should inquire about the patient's smoking history, assess skinfold thickness, and examine the toes for hair loss and deformities, to predict PAD.

A detox dilemma beyond benzodiazepines; clonidine's quandary in alcohol withdrawal management.

Benzodiazepines are the primary method of treatment of alcohol withdrawal, though the American Society of Addiction Medicine guidelines also include alternative agents for consideration. Observations in a Department of Veterans Affairs (VA) psychiatric emergency room noted consistent benzodiazepine use with an overall lack of use of alternative agents, even with low Clinical Institute Withdrawal Assessment for Alcohol (CIWA) scores and in the absence of other concerning symptoms. Due to concerns of potential more-than-necessary benzodiazepine use, we analyzed adjunctive clonidine use for elevated blood pressure/pulse in alcohol withdrawal among this Veteran population. This is a single-site VA retrospective chart review of the psychiatric emergency room from July 1, 2022, to June 30, 2023, focused on patients with alcohol withdrawal managed on a CIWA protocol. Excluding concurrent opioid withdrawal and clonidine as home medication, 167 patient charts were analyzed for this study. Among 167 patients, 99 (59.3%) had comorbid hypertension. A total of 614 medication doses were given for elevated CIWA (373, 60.8%) and elevated blood pressure/pulse (241, 39.2%). Of the 241 doses for elevated blood pressure/pulse, only 2.5% were clonidine. Among all benzodiazepine doses, 75.3% were given to patients with comorbid hypertension. Clonidine was administered to 3.0% of patients, making up 2.5% of total dosing. Alcohol withdrawal management lacks optimization. Integrating adjunctive medications could reduce potential benzodiazepine overuse effectively addressing elevated blood pressure/pulse. This study sheds light on the potential underutilization of clonidine and its potential role in improving alcohol withdrawal syndrome management. By addressing elevated blood pressure/pulse and curbing potential overuse of benzodiazepines, it may contribute to further optimizing patient care.

Abstract We107: Reduction of Six-Month Heart Failure Readmission Rates in Patients Undergoing MitraClip with Beta Receptor Blockade

Introduction: MitraClip has been shown to reduce heart failure readmissions in patients with moderate to severe mitral valve regurgitation. Likewise, beta-blocker (BB) therapy has been shown to reduce morbidity and mortality in select heart failure patients. At the cellular level, chronic myocardial insult from ongoing heart failure and mitral regurgitation leads to persistent overstimulation of myocardial beta-receptors, ultimately reducing cardiac inotropic reserve and contributing to myocardial injury. Thus, we hypothesized that patients on beta-blocker therapy before the MitraClip procedure would have fewer heart failure-related readmissions. Hypothesis: We assessed the hypothesis that beta-blocker therapy before the MitraClip procedure would lead to fewer heart failure-related readmissions by conducting a retrospective cohort study. This would help us better understand the pathogenesis of re-admissions in this patient population as well as help us decide whether prophylactic initiation of BB therapy before the procedure would reduce the risk of heart failure readmissions. Methods: We reviewed the records of patients who underwent the MitraClip procedure at our institution from January 2017 to July 2022. Patients without listed home medications, as well as non-heart failure-related readmissions and deaths, were excluded. Patients were split into those on BB therapy and those with no BB therapy. Of the 401 charts screened, 324 met the inclusion criteria. Results: From those who met the inclusion criteria, 226 patients were on beta-blocker therapy, while 98 patients were not. Of those who had at least one heart failure-related readmission within 6 months of the MitraClip procedure, 18 patients were on beta-blocker therapy and 16 patients were not. Meaning a 7.96% readmission rate for patients on beta-blocker therapy, and a 16.32% readmission rate for those who were not (OR 2.05, 95% CI: 1.004 to 4.186, p&lt;0.05), with the number needed to treat being 11.9. Conclusions: Our data shows that the use of beta-blocker therapy was associated with a statistically significant decrease in 6-month heart failure readmissions in those undergoing the MitraClip procedure. This suggests that at the cellular level, cardiac beta receptor dysfunction plays an integral part in future hospitalizations in this population. In conclusion, beta-blocker therapy should be considered in heart failure patients planning to undergo the MitraClip procedure to reduce heart failure-related readmissions.

Achieving Enteral Autonomy in Children with Intestinal Failure Following Inpatient Admission: A Case Series

We describe cases of intestinal failure wherein inpatient admission was critical toward enteral autonomy. We performed a retrospective chart review of 6 children with long-term parenteral nutrition dependence who were weaned from parenteral nutrition following admission. Admissions included feeding and medication titration, interdisciplinary care, and home parenteral nutrition team consultation.