2026 Eastern States Conference

Authors: Madhura Pradhan, PharmD; Nadirah El Amin, DO; Jennifer Newlin, PA-C; Cady Noda, PharmD, BCPPS 

Objective: At the conclusion of my presentation, the participants will be able to explain the clinical benefit and safety of hydroxyurea in patients with hemoglobin SC disease of all ages.  

Self-Assessment Question: True or False: Primary literature and this current project recommend restricting the use of hydroxyurea to patients with HbSC aged 18 years and older due to higher rates of neutropenia in patients less than 18 years of age. Answer: False 

Background: Current sickle cell disease (SCD) guidelines offer vague recommendations for hydroxyurea (HU) use in patients with hemoglobin SC disease (HbSC). We aim to characterize HU use in patients with HbSC of all ages at a large academic medical center. 

Methods: This quality improvement project is a retrospective chart review of pediatric and adult patients diagnosed with HbSC who were prescribed hydroxyurea. Primary outcome was vaso-occlusive crisis (VOC) and acute chest syndrome (ACS), stratified and compared via proportion of days covered (PDC) status: low PDC vs moderate PDC vs high PDC. Secondary outcomes include average HbF, average total Hgb, hospitalization for any reason, incidence of neutropenia or thrombocytopenia, and incidence of hydroxyurea discontinued by the patient or medical team, all within the last 12 months. Data was analyzed via descriptive statistics for continuous data and Fisher’s Exact Test for nominal data. 

Results: There were 109 patients who had a diagnosis of HbSC and prescribed HU. More patients fell in the low PDC group (63.3%) vs moderate PDC (8.26%) vs high PDC (28.44%) groups. Median number of VOC was 1 event [IQR 0 – 6] in the low PDC group, and 1 event [IQR 0-4.75] in the moderate-to-high PDC groups (p=0.987). Median number of ACS events was 0 in both the low PDC and moderate-to-high PDC groups (p=0.117). There was no difference in incidence of neutropenia (p=0.636), thrombocytopenia (p=1.0), HU stopped by the team (p=0.296), or HU stopped by the patient (p=0.737) within the last 12 months in the low PDC and moderate-to-high PDC groups.  

Conclusions: Patients with HbSC demonstrated low adherence to hydroxyurea based on PDC measurements. Rates of VOC events were similar between the low PDC and moderate-to-high PDC groups. The low incidence of thrombocytopenia and neutropenia supports the safety of HU in this population. These findings highlight the need to improve medication adherence while continuing to offer HU to patients with HbSC at our institution.   

Risk Factors for Surgical Site Infections in Orthopedic Surgery: A Case-Control Study 
Lama Almutairi, Michael Klompas, James Maguire, Madeleine Bartzak, Brandon Dionne, Jeffrey C. Pearson

Background/objective:
Surgical site infections (SSIs) complicate orthopedic surgery, highlighting the need to clarify associated risk factors. By the end of the presentation, participants should be able to identify risk factors for SSIs in hip or knee surgery.

Methods:
This was a single-center retrospective case-control study conducted at a tertiary academic medical center. Patients who underwent orthopedic knee or hip surgery between August 2020 and May 2025 were included. Cases were patients who developed an SSI within 90 days, according to the National Healthcare Safety Network criteria. Controls were patients who did not develop an SSI within the same follow-up period. Cases were matched 1:4 to controls by surgery type (hip vs. knee) and procedure date (month and year). The association between risk factors and SSIs was assessed using univariable and multivariable logistic regression. Prespecified risk factors included body mass index (BMI) ≥25 kg/m², diabetes mellitus with most recent A1C ≥7%, surgical duration ≥120 minutes, age ≥60 years, S. aureus nares screening, and perioperative antibiotic choice (cefazolin alone vs. other).

Results: 
Among 250 patients (50 cases, 200 controls), the mean BMI was 30.2 kg/m² for cases and 27.9 kg/m² for controls. Hypertension was present in 62% of cases versus 55% of controls, and diabetes was present in 24% of cases versus 14.5% of controls. Perioperative antibiotic regimens were similar between groups: cefazolin alone was used in 48% of cases vs 49% of controls, while cefazolin plus vancomycin was used in 40.0% vs 43.5%. S. aureus was the most common pathogen. Of the prespecified risk factors, BMI ≥25 kg/m² [adjusted odds ratio (aOR) 3.59, 95% confidence interval (CI) 1.21-10.66] and surgical duration ≥120 minutes [aOR 2.30, 95% (CI) 1.18-4.48] were each associated with an increased risk of SSIs in the multivariable regression analysis.

Conclusion:
These findings provide insight into risk factors associated with SSIs, which can be considered to optimize peri-operative practices to reduce SSIs risk in patients undergoing orthopedic surgery.

Assessment Question
Which of the following perioperative risk factors has been associated with an increased risk of surgical site infection following orthopedic surgery?

1. Age younger than 50 years

1. Surgical duration ≤60 minutes

1. Body mass index ≥25 kg/m²
2. Cefazolin alone for surgical prophylaxis

Correct answer: C

Evaluation of hemorrhagic conversion and use of fibrinogen products after fibrinolytic therapy for acute ischemic stroke 

Authors
Norah Albanyan PharmD; Nihad Medar PharmD, BCCCP; Patricia Cyrus PharmD, BCPS; Melanie Goodberlet PharmD BCPS, BCCCP; Skyler Starkel PharmD, BCCCP

Learning Objective
Describe the differences in hemorrhagic conversion and bleeding outcomes between tenecteplase (TNK) and alteplase (tPA) in acute ischemic stroke.

Self-Assessment Question 
In this retrospective cohort study comparing tPA and TNK for acute ischemic stroke, what was observed regarding intracranial hemorrhagic (ICH) conversion within 24 hours?

A. TNK was associated with a significantly higher rate of ICH
B. tPA was associated with a significantly higher rate of ICH
C. There was no statistically significant difference in ICH between tPA and TNK
D. TNK eliminated the risk of ICH compared to tPA

Background /objective
Acute ischemic stroke (AIS) is a leading cause of morbidity and mortality. Alteplase (tPA) or tenecteplase (TNK) are used to improve outcomes. This study compares incidence of hemorrhagic conversion and use of fibrinogen products following tPA or TNK

Method
This was a single-center retrospective cohort study at a tertiary academic medical center approved by the Mass General Brigham Institutional Review Board (2025P002247). Adult patients (≥18 years) with AIS treated with tPA or TNK between January 2020 and October 2025 were included. Our institution transitioned to TNK as the preferred fibrinolytic agent for AIS in June 2023. Patients were excluded if 24-hour post-treatment neuroimaging was unavailable or thrombolytic dosing was outside guideline recommendations

The major outcome was intracranial hemorrhagic conversion within 24 hours. Minor outcomes included extracranial bleeding, time to hemorrhagic conversion, post-lysis fibrinogen levels, fibrinogen product use, and 30-day mortality. Categorical outcomes were compared using chi-square or Fisher’s exact tests, continuous variables using t-test or Mann–Whitney U test. A multivariable logistic regression identified independent predictors of hemorrhagic conversion.

Results
A total of 114 patients met eligibility, 55 (48.2%) received TNK and 59 (51.8%) tPA. Hemorrhagic conversion within 24 hours occurred in 6 patients in the TNK group and 7 in the tPA (10.9% vs 11.8%, p=0.87). There was no difference in time to hemorrhagic conversion, extracranial bleeding within 24 hours, or mortality between groups. Replacement with fibrinogen products was only seen in the tPA group (4 patients). Median fibrinogen at hemorrhagic conversion 381 mg/dL (TNK) vs 138.5 mg/dL (tPA). When controlling for confounders, a higher National Institutes of Health Stroke Scale score was associated with hemorrhagic conversion.

Conclusion  
In this retrospective cohort of patients with AIS, TNK and tPA had similar rates of hemorrhagic transformation, extracranial bleeding, and 30-day in-hospital mortality, suggesting comparable bleeding safety profiles between the two agents in our cohort. Notably, fibrinogen product use was observed only in the tPA group, which had lower fibrinogen levels. Further research is needed to better define optimal reversal strategies for these agents.

Authors: Ngan Le, PharmD; Lauren Albertina, PharmD, BCCCP; Kimberly Hall, PharmD, BCCP, BCPS 

Learning Objective: Audience members will be able to explain the role of colchicine in the prevention of post-operative atrial fibrillation (POAF) following cardiothoracic surgery. 

Background/Objective: The purpose of this study is to evaluate the safety and effectiveness of the addition of colchicine to institutional standard of amiodarone and beta blocker therapy for the prevention of POAF in patients who have undergone cardiothoracic surgery. 

Methods: This single-center retrospective cohort study was conducted at Inova Fairfax Medical Campus. Adults (≥18 years) undergoing cardiothoracic surgery requiring cardiopulmonary bypass were included. Exclusion criteria were renal dysfunction, acute kidney injury, transaminitis, chronic liver disease, congenital heart disease, or colchicine use for other indications. The colchicine group consisted of patients from January-June 2025 who received colchicine 0.6 mg twice daily starting on postoperative day two. The control group consisted of patients from January-June 2024 who did not receive colchicine post-operatively. The primary outcome was the incidence of POAF. Secondary outcomes included the incidence of post-operative pericarditis, postpericardiotomy syndrome, and post-operative ileus. Safety outcomes included any events warranting colchicine dose reduction or discontinuation. Categorical variables were analyzed via two-sided Fisher’s exact or Pearson Chi-square tests where appropriate. 

Results: Over the pre-specified periods, 160 patients were included (colchicine n= 81, control n= 79). As part of the institutional POAF prophylaxis protocol, 84.4% of patients received amiodarone and 88.1% received beta blockers. POAF occurred in 19 patients (23.5%) in the colchicine group and in 23 patients (29.11%) in the control group (p=0.42). The median onset of POAF was three days after surgery. Secondary outcomes showed no difference in the incidence of post-operative pericarditis, postpericardiotomy syndrome, and post-operative ileus. Colchicine dose reduction occurred in 4.9% of patients, and discontinuation occurred in 21.0% of patients, most commonly due to diarrhea. 

Conclusions: Among patients undergoing cardiothoracic surgery, the addition of colchicine to institutional standard amiodarone and beta blocker therapy did not significantly reduce the incidence of POAF. Diarrhea was the most common adverse event leading to colchicine dose reduction or discontinuation. The study limitations included retrospective study design and limited sample size.  

Self-Assessment Question: According to our study, colchicine showed reduced incidence of post-operative atrial fibrillation in patients undergoing cardiothoracic surgery (True/False) 

Title: Development of a specialty pharmacy electronic order set in reproductive endocrinology

Authors:
Shekinah Banson, PharmD, MS, Kamaria Cayton Vaught, MD, Lauren Lakdawala, PharmD, BCACP, Jennifer Costello, MSN, RN, C-EFM, Emmanuel Vasilarakis, PharmD, BCACP, Nolan Kauffman, PharmD, Amy Nathanson, PharmD, BCACP, Molly Wascher, PharmD, MBA, BCPS

Learning Objective:
Describe challenges in fertility medication ordering and dispensing that aid in the development of an Epic SmartSet for reproductive endocrinology and infertility (REI).

Self-Assessment Question: 
What current challenges are associated with manual fertility medication ordering among providers and pharmacists, and how can a standardized SmartSet be a solution?

A. The absence of an Epic SmartSet leads to manual, inconsistent ordering, increasing workloads and delaying patient care; a standardized SmartSet can improve order accuracy and efficiency
B. Variability in patient response to fertility medications requires frequent dose adjustments; individualized clinical decision-making limits the usefulness of standardized SmartSet
C. The complexity of fertility treatment protocols necessitates flexibility, provider-specific ordering approaches; standardized order sets may restrict clinical autonomy and adaptability
D. Insurance coverage and prior authorizations expedite therapy for fertility medicine, a standardized order SmartSet would have minimal impact on these external barriers

Background/Objective:
The absence of an Epic SmartSet for fertility protocols leads to manual, inconsistent ordering, increasing workload, and delaying of patient care. This project aims to improve order accuracy and efficiency for nursing, providers, and pharmacy teams.

Methods: 
This quality improvement project is being conducted at The Johns Hopkins Hospital and Johns Hopkins Green Spring Station (GSS). Baseline data was collected using an anonymous REDCap® survey of providers, nurses, pharmacists, and pharmacy technicians to assess current ordering workflows. Descriptive data on the amount of fertility medication orders from December 1, 2024, to November 30, 2025, was obtained. Survey and prescribing data will inform the development of a standardized Epic SmartSet. The finalized SmartSet will be submitted to Johns Hopkins Reproductive Endocrinology Physician for building and implementation.

Results:
From December 1, 2024, to November 30, 2025, 31,772 fertility medication orders were generated at the GSS REI Clinic. 14,501 of those were sent to Johns Hopkins Outpatient Pharmacies with the majority routed to GSS (11,076), followed by Holabird Specialty Pharmacy (1,807) and Arcade Pharmacy (1,414), with smaller volumes distributed across additional Johns Hopkins outpatient pharmacies. According to the survey, missing or incorrect supplies were the most frequently reported issue by the pharmacy team. Additionally, 67% of the clinical team and 70% of the pharmacy team reported challenges with switching to alternative agents.100% of respondents reported they would be very likely to use a standardized order set.

Conclusion: 
Standardized Epic SmartSets with embedded decision support may address order completeness, provide allowed alternatives, and reduce prescribing ambiguity. This may support more consistent ordering and prescribing practices. The reduction in variability will enhance interdisciplinary workflow, providing a scalable framework for optimizing ordering processes across specialty areas.

Authors: Rachel Rivers, PharmD; April Finnigan, PharmD, BCCCP; Stefan Leichtle, MD, FACS; Jenna Smith, PharmD, BCCCP

Presentation Objective: Audience members will be able to describe the proposed pathophysiologic mechanisms of beta-blocker and amantadine therapy for neurological recovery in traumatic brain injury (TBI) patients.   

Background: This study aims to bridge the evidence gap for dual propranolol and amantadine therapy in adult TBI patients, namely, to assess the impact of dual therapy on cognitive recovery.

Methods: This was a single-center retrospective cohort study of adult patients with moderate-severe TBI between January 1, 2020 and December 31, 2024. Study subjects were excluded if they received propranolol or amantadine for an indication outside of TBI or prior to admission. The study population was stratified to three subgroups: patients who received dual therapy, patients who received amantadine only, and a control group in which participants received neither therapy. The primary endpoint was defined as the change in total Glasgow Coma Scale (GCS) score from baseline to day seven of therapy or admission. Secondary endpoints included change in motor GCS, peak GCS at therapy discontinuation and hospital discharge, ICU and hospital length of stay, use of adjunctive agents for agitation, and days of therapy with a Richmond Agitation-Sedation scale score > +1. Continuous endpoints were analyzed using the Kruskal-Wallis test and categorical endpoints using Pearson’s chi-squared statistics.

Results: Of 200 patients screened, 120 were included in the study population. Statistical analysis revealed significant improvement in total and motor GCS scores from admission to day seven in all subgroups, and from day one of therapy to day seven among the amantadine and dual therapy subgroups. However, the median score changes were comparatively similar between arms. Subjects in the amantadine and dual therapy arms had a greater incidence of neurosurgical intervention and intracranial pressure monitor placement, longer hospital and ICU LOS, and lower baseline GCS, suggesting more critical injury. The control population was noted to have a significantly greater incidence of agitation, with more frequent adjunct agent use and RASS scores > +1.

Conclusion: While outcome analyses did not reveal significant improvement in neurological recovery in the treatment subgroups compared to the control population, the variability in baseline characteristics and illness severity as well as treatment timeline should be noted. The greater incidence of adjunctive agent use for agitation in the control arm may suggest an accessory role of propranolol and amantadine in TBI symptom management. Post-hoc analyses are needed to delineate key between-group differences.

Self-Assessment Question: Which of the following statements describe the role of beta-blocker therapy in traumatic brain injury? (select all that apply) 
A. Beta-blockers play a preventative role in paroxysmal sympathetic hyperactivity by helping to blunt sympathetic overtone.  
B. Beta-blockers regulate disrupted dopaminergic and glutaminergic pathways.  
C. Beta-blockers reduce cerebral metabolic demand.
D. Beta-blockers increase myocardial oxygen demand.

TITLE: Evaluation of gabapentinoid therapy and impact on chronic non-cancer pain for patients on concomitant chronic opioid therapy

AUTHORS:
Destiny Walker, PharmD
Laurence Martinez, PharmD, BCACP
Julia Kaminski, PharmD

LEARNING OBJECTIVE: Audience members will be able to evaluate the risk versus benefit of concomitant gabapentinoids and chronic opioid therapy to mitigate opioid dose escalation.

OBJECTIVE: The primary objective is to assess the impact on morphine milligram equivalents (MME) and safety outcomes for Veterans utilizing gabapentinoid therapy in combination with chronic opioid therapy compared to patients on opioid monotherapy.

METHODS: The Coatesville Veterans Affairs Medical Center (CVAMC) operates a multidisciplinary outpatient pain clinic managing high risk patients on chronic opioid therapy with complex comorbidities. This retrospective, single-center study reviewed Veterans who received chronic opioid therapy and were enrolled in the pain clinic between November 4th, 2022, and August 25th, 2025. The study aimed to evaluate the impact on MME and safety outcomes for Veterans prescribed opioids and gabapentinoids, and those prescribed opioid monotherapy by a CVAMC pain provider. Exclusion criteria encompassed patients initially prescribed tramadol, codeine with acetaminophen, buprenorphine, or gabapentinoids prior to opioids. Patients had to be prescribed therapy from CVAMC pain provider. If prescribed opioids for acute conditions and cancer pain the patients were excluded. A subgroup analysis was completed to further examine any outliers within the study groups, including rapid tapers and changes in therapy.

RESULTS: There were 117 Veterans’ charts reviewed, 63 patients were excluded primarily due to the initiation of gabapentinoid therapy prior to opioid therapy. A total of 24 patients were included in the gabapentinoid with concomitant opioid therapy group, while 30 patients were included in the opioid monotherapy group. The average change in MME was -4.36 in the gabapentinoid with opioid group and -19.66 in the opioid monotherapy group. The gabapentinoid with opioid group reported limited side effects, with somnolence being the most common effect with 8.3%. All participants were prescribed naloxone and received opioid overdose prevention education. No opioid overdoses were reported during the study period.

CONCLUSION: Adjuvant gabapentinoid therapy with chronic opioid therapy can be considered to further reduce pain with minimal side effects if all non-opioid treatments have been exhausted and risk mitigation strategies are utilized. Despite a greater reduction in mean MME in the opioid monotherapy group, the gabapentinoid with opioid therapy also saw MME reductions, possibly influenced by patient specific factors like etiology of pain, non-opioid therapies, and patient hesitancy with opioid dose reduction.

SELF-ASSESSMENT QUESTION:  Can gabapentinoids be an effective adjuvant therapy for patients on long-term opioid therapy to mitigate opioid dose escalation without increasing risks?

Authors: 
Kayleigh Early, PharmD; Brittany Thomas, PharmD, BCIDP; Alison Sabados, PharmD, BCCCP 
 
Learning Objective: 
Describe the impact of rapid molecular blood culture diagnostics on antimicrobial optimization and stewardship interventions in adult patients with bloodstream infections.
 
Background: 
Bloodstream infections are associated with increased morbidity and mortality, and delays in therapy worsen outcomes. Blood culture identification (BCID) panel implementation, with antimicrobial stewardship, may shorten time to therapy optimization.
 
Methods: 
This retrospective, pre–post cohort study evaluated adult patients aged 18 years or older admitted to WellSpan York Hospital with at least one positive blood culture in September 2023 (pre-BCID implementation) or September 2025 (post-BCID implementation). The primary outcome was time to appropriate antimicrobial therapy. Secondary outcomes included time to first antimicrobial change, time to antimicrobial escalation or de-escalation, days of therapy, and the number, type, and timing of pharmacist-driven antimicrobial interventions, as well as hospital length of stay and in-hospital mortality.

Results: 
A total of 109 patients were included (52 pre-BCID implementation, 57 post-BCID implementation) with similar baseline characteristics between groups. There was no difference in time to appropriate antimicrobial therapy (0 vs. 0 hours, p=0.746). Time to first antimicrobial change was significantly reduced (36.2 vs. 12.1 hours, p=0.007), with faster de-escalation (43.7 vs. 18.6 hours, p=0.016) but no difference in time to escalation (27.4 vs. 4.4 hours, p=0.342). Pharmacist interventions increased, with shorter time to intervention (39.2 vs. 13.6 hours, p=0.045). No differences were observed in days of therapy, hospital length of stay, or in-hospital mortality.

Conclusion: 
Implementation of a BCID panel improved the timeliness of antimicrobial optimization, including faster de-escalation and pharmacist-driven interventions. Despite these improvements, no differences were observed in time to appropriate antimicrobial therapy, time to escalation, or clinical outcomes. These findings suggest empiric regimens, guided by local antibiograms and institutional protocols, were generally appropriate, with BCID further enhancing timely antimicrobial optimization.  

Self-Assessment Question:
A hospitalized adult is started empirically on vancomycin and cefepime for suspected bacteremia. Rapid BCID panel results return. 
In which scenario should rapid identification prompt an urgent change in antimicrobial therapy? 
A. MSSA identified; patient receiving vancomycin and cefepime 
B. E. coli identified; patient receiving vancomycin and cefepime 
C. MRSA identified; patient receiving vancomycin and cefepime  
D. Candida glabrata identified; patient receiving vancomycin and cefepime

Title: Bridging the gap: Impact of discharge medication provision on psychiatric readmission rates 
  
Authors: Alexis Roman, PharmD; Madeline Corrao, PharmD; Sabra Douthit, PharmD 
 
Objective: Evaluate the impact of discharge medication delivery through a Meds to Beds (M2B) program, compared with patient pickup at a community pharmacy, on 30-day psychiatric hospital readmission rates. 

Self-Assessment Question: Which factor is most strongly associated with psychiatric hospital readmissions during transitions of care?
A. Short inpatient length of stay
B. Dose adjustments during hospitalization 
C. Medication nonadherence after discharge
D. Overuse of long-acting injectable therapies
  
Background: Psychiatric inpatients who receive discharge medications prior to leaving the facility experience significantly lower 30-day readmission rates than those discharged with prescriptions filled at an outside community pharmacy.  
 
Methods: This retrospective cohort study will use electronic medical record (EPIC) data to compare adult psychiatric inpatients discharged with medications through a Meds to Beds (M2B) program versus prescriptions filled at community pharmacies. Eligible patients will be ≥18 years old, admitted to Geisinger Behavioral Health Northeast, discharged on at least one medication, and have a primary psychiatric diagnosis; patients discharged to a state hospital or who expired within 30 days post‑discharge will be excluded. Data from August 1, 2023, to July 31, 2025, will be analyzed (estimated n=200), with 30‑day psychiatric readmission as the primary outcome with 7‑ and 14‑day readmissions as secondary outcomes; descriptive statistics and comparative analyses (Fisher’s exact tests) will be performed. 
 
Results: A total of 200 patients were included (M2B n=130, community n=70). Thirty-day readmission rates were similar between groups (16.2% vs. 15.7%; RR 1.03, 95% CI 0.58-2.01; p>0.999). No meaningful differences were observed at 7 days (5.2% vs. 4.8%; RR 1.08, 95% CI 0.31-3.85) or 14 days (9.9% vs. 7.8%; RR 1.27, 95% CI 0.49-3.36). Overall event rates were low, resulting in wide confidence intervals and limited precision of estimates.

Conclusions: Meds to Beds was not associated with lower psychiatric readmission rates compared to community pharmacy pickup. These findings suggest medication delivery alone may have limited impact on readmissions and highlight the need to address broader factors influencing outcomes during transitions of care.

Title: Appropriateness of venous thromboembolism prophylaxis prescribing in acutely ill medical patients 

Authors: Seharpreet Sethi, PharmD; Geoffrey Arentz, PharmD, BCPS; Christine Higgins, RPh, BCPS 

Learning Objective: Audience members will be able to identify patients who are appropriate to receive venous thromboembolism (VTE) prophylaxis.  

Self Assessment Question: At the conclusion of my presentation, the participant will be able to recognize appropriate prescribing of VTE prophylaxis.

Background/Objective: The purpose of this study was to identify the appropriate usage of VTE prophylaxis in the inpatient setting. Guidelines for VTE prophylaxis refer to the IMPROVE VTE and Bleed scores as a method of risk assessment before starting. 

Methods: This retrospective chart review included patients >18 years admitted in three medical floors, medical, and cardiac ICU, who received VTE prophylaxis between July 1 and August 8, 2025. The exclusion criteria included admissions for bleeds, pregnant and postpartum patients, repeat admissions, and therapeutic anticoagulation orders. The primary objective was the percentage of inappropriate VTE prophylaxis prescribing, based on IMPROVE VTE and IMPROVE Bleed scores. Secondary outcomes include bleeding 48 hours after last dose of prophylaxis given, the percentage of patients ineligible based on their IMPROVE VTE score, percentage of patients ineligible based on their IMPROVE Bleed score, and percentage of appropriate VTE prophylaxis prescribing in the ICU compared to non-ICU settings.  

Results: A total of 248 patients met the inclusion criteria, and 64 patients were excluded, leading to a total of 184 patients being studied. The primary objective revealed that 69% of total included patients had inappropriately received VTE prophylaxis based on their IMPROVE scores. Looking at the secondary outcomes, 3 patients experienced a bleed. 2 of these patients were ineligible to receive prophylaxis, while 1 was eligible. 67% of patients deemed ineligible for VTE prophylaxis did not meet criteria to start due to a low IMPROVE VTE score. Overall, percentages of ineligible and eligible patients were similar between ICU and non-ICU patients.. 
 
Conclusion: Application of the IMPROVE VTE and Bleeding risk scores to assess appropriateness for VTE prophylaxis suggests that prophylaxis may be overprescribed in the inpatient setting, including both ICU and non-ICU populations. Pharmacists in different practice areas should continuously evaluate a patient’s risk of VTE and bleeding to potentially deescalate prophylactic prescribing, which could improve patient satisfaction and cost savings. 

Title: Use of insulin NPH in patients with steroid-induced hyperglycemia

Authors: McCleary D, Van Slyke B, Schaefer M, Calder T

Learning Objective: Evaluate the effects of insulin NPH on hyperglycemia management outcomes and safety considerations.

Self-Assessment Question: Which insulin strategy best aligns with the glucose-raising pattern of glucocorticoids in steroid-induced hyperglycemia?

Background/Objective: Glucocorticoids are widely used for their immunosuppressive and anti-inflammatory effects but often cause hyperglycemia. This study evaluates the effectiveness of NPH insulin versus non‑NPH regimens in managing steroid‑induced hyperglycemia.

Methods: A two‑month retrospective chart review will be conducted from November 1, 2025, to December 31, 2025, for patients started on glucocorticoid therapy who meet inclusion criteria. These patients, identified through an automated report, will serve as the intervention‑free control period. A subsequent two‑month prospective phase from January 1, 2026, to February 28, 2026, will evaluate the insulin NPH intervention. Included patients must be initiated on glucocorticoid therapy exceeding 10 mg prednisone equivalents per dose, have two or more blood glucose readings above 180 mg/dL in the first 24 hours of therapy or a history of diabetes, and be ≥18 years old. Exclusion criteria include hypoglycemia during the current admission, treatment for DKA or HHS, or age <18. The primary outcome is the rate of blood glucose readings >180 mg/dL while on glucocorticoids. The safety outcome is the rate of hypoglycemia events.

Results: A total of 42 patients met inclusion criteria, including 24 in the retrospective control group and 18 in the prospective insulin NPH group. Baseline characteristics were comparable between groups. There was no statistically significant difference in the rate of hyperglycemia between patients managed without insulin NPH and those receiving insulin NPH (43% vs 43%; P = 0.99). Among patients with ≥2 blood glucose readings >180 mg/dL within the first 24 hours of glucocorticoid initiation, the mean rate of hyperglycemia was 52% in the non–insulin NPH group and 43% in the insulin NPH group (P = 0.39). One hypoglycemia event occurred in the non–insulin NPH group compared with four events in the insulin NPH group.

Conclusion: Insulin NPH use for steroid‑induced hyperglycemia did not result in a statistically significant reduction in hyperglycemia compared with non–insulin NPH therapies. However, the pharmacodynamic profile of insulin NPH closely aligns with glucocorticoid‑related glucose elevations. Optimized dosing strategies, standardized protocols, and larger studies are needed to better define its role in managing steroid‑associated hyperglycemia.