2026 Eastern States Conference

Authors
Saqib Khan, PharmD; Eric Boateng, PharmD, BCOP; Sonjela Bulku, PharmD, MS; Scott Tam, PharmD, BS; Momina Qureshi, PharmD; Kyoung-Sil Kang, PharmD, BCPS, BCOP

Learning objective
At the conclusion of this presentation, participants will be able to identify the onset timeline of pembrolizumab-associated hypothyroidism and describe the corresponding patterns of initiation of thyroid hormone replacement treatment in adult patients.

Self-assessment question
Which of the following best describes pembrolizumab-associated hypothyroidism?

1. It usually occurs before treatment initiation
2. It is a common immune-related adverse event that may occur weeks to months after starting therapy
3. It occurs only in patients receiving combination immunotherapy
4. It does not affect the quality of life or cancer treatment

Background
While Pembrolizumab has been shown to improve outcomes in solid tumors, it may cause hypothyroidism. Real-world data on the time to onset in underserved outpatients are limited. This study evaluates the time to onset of hypothyroidism after pembrolizumab initiation.

Methods
This is a retrospective study of patients who received at least 3 doses of pembrolizumab between January 2023 to July 2025. Patients included had a baseline thyroid-stimulating hormone (TSH) before pembrolizumab initiation. Patients with pre-existing hypothyroidism, on thyroid hormone treatment, or prior thyroidectomy were excluded. Data collected included demographics, cancer type, pembrolizumab dose and treatment dates, TSH and free thyroxine levels, date of hypothyroidism diagnosis, and date of thyroid hormone replacement therapy initiation. The primary endpoint is the time from pembrolizumab initiation to the onset of hypothyroidism. Secondary endpoints include time from documented hypothyroidism to thyroid hormone replacement therapy, as well as the proportion of patients remaining untreated at 30 days post diagnosis.

Results
A total of 38 patients met the inclusion criteria. The mean age was 66.3 ± 12.5 years, and 71.1% were female. The majority of patients were identified as Hispanic/Latino (52.6%) or Black (34.2%). The most common cancer type was breast (39.5%), followed by lung (21.1%) and uterine (15.8%), with a mean of 11.3 ± 6.6 treatment cycles. Hypothyroidism, defined as TSH greater than 10 mIU/L, occurred in 11 of 38 patients (28.9%). Of these, 45.5% developed hypothyroidism within 3 months of initiation, 18.2% between 3 and 6 months, and 36.4% after 6 months. Of the 11 patients diagnosed, 5 (45.5%) initiated levothyroxine within 30 days, while 6 (54.5%) remained untreated at 30 days post-diagnosis.

Conclusion
Pembrolizumab-associated hypothyroidism occurred in nearly 29% of patients, with over one-third presenting after 6 months of therapy. More than half of diagnosed patients remained untreated at 30 days, identifying a critical gap in timely clinical management. These findings support ordering TSH and free T4 together at every monitoring visit, continuing surveillance beyond 3 months, and implementing structured follow-up workflows to ensure prompt treatment initiation in underserved outpatient populations.

Title: Characterizing institutional uses of vedolizumab for immune checkpoint inhibitor (ICI) colitis
Authors: Amrit Pabla, PharmD; Christopher Wang, PharmD, BCOP; Lina Shao, PharmD, BCOP; Aliyah Pabani MD, MPH; Joanna Melia, MD; Vi Gilmore, PharmD, BCPS
Abstract 
Objective: This study aims to characterize institutional prescribing patterns of vedolizumab prior to and after implementation of formulary restriction changes and evaluate its clinical outcomes among patients with ICI colitis at Johns Hopkins Medicine. 
Methods: This retrospective, single-health system study evaluated adult patients with ICI colitis that received vedolizumab from July 2024 to July 2025. Patients were included if they received at least one dose of ICI therapy, had a diagnosis of ICI colitis, and received at least one dose of vedolizumab. Patients were excluded if they were less than 18 years of age. The objectives of this study were to characterize the prescribing practices of vedolizumab for ICI colitis 6-months before and after implementation of formulary restriction changes in January 2025, report efficacy and safety outcomes of vedolizumab for ICI colitis and to characterize ICI rechallenges for patients who had resolution of their ICI colitis.
Results: A total of 23 patients were included, of which 12 patients were in the pre- implementation cohort, and 11 were in the post- implementation cohort. The median age was 71 years old, 38% were female, and all patients were white. Most patients had melanoma (48%) and received combination ICI therapy (61%). Vedolizumab was prescribed first-line following steroids in 91% of patients. A second immunosuppressant agent was required in 17% of patients for refractory symptoms. Infections occurred in 35% of patients, with median time to first infection of 37 days. Readmission for recurrent ICI symptoms occurred in 13% of patients, and ICI rechallenges occurred in 30% of patients. All patients with a rechallenge had no recurrent symptoms.
Conclusions: This study characterizes the institutional prescribing patterns of vedolizumab at a single center health system and adds to existing literature supporting the use of vedolizumab for steroid refractory ICI-colitis.
Self-Assessment Question: (True/False) Vedolizumab is a non-steroidal immunosuppressant option for treating steroid refractory ICI induced colitis.

Authors 
Catherine Murphy, PharmD; Andrew Webb, PharmD; Riley Johnson, PharmD 
 
Learning Objective 
Describe outpatient nimodipine prescribing practices upon hospital discharge in patients with aneurysmal subarachnoid hemorrhage. 

Background/Objective
It is unclear if the full 21-day nimodipine course is needed for patients with aneurysmal subarachnoid hemorrhage (aSAH) who are ready for discharge prior to day 21. Thus, we assessed nimodipine prescription rates at discharge in patients with aSAH. 

Methods
This was a single-center, retrospective cohort study of adults (age ≥18 years) admitted for the management of aSAH who were treated with nimodipine during their hospitalization and discharged prior to day 14. Data collected included age, sex, past medical history, aneurysm characteristics, duration of hospitalization, duration of inpatient nimodipine, and outpatient nimodipine prescribing information. The primary outcome was the rate of nimodipine continuation after discharge, which was defined as a prescription being issued to an outpatient pharmacy. Secondary outcomes included the duration of hospitalization;, the duration of outpatient nimodipine treatment;, number of 90-day follow-up appointments;, rehospitalizations,; occurrence of cerebral vasospasm and delayed cerebral ischemia during admission,; and occurrence of rebleeds.

Results
A total of 94 patients admitted between 2016 and 2025 were assessed, of which 88 patients were included. The median age was 55.5 years, and 58 patients (66%) were female. The median modified Fisher and Hunt Hess scores were 3 and 2, respectively. Overall, 47 patients (53.4%) were issued a prescription for nimodipine at discharge. Of the patients prescribed nimodipine, 3 (6.4%) were nonadherent to nimodipine therapy, 8 (17%) had documentation of adherence, and 36 (76.6%) of patients had unknown adherence. 4 patients who continued nimodipine had a significant finding on their follow-up angiogram, defined as a recurrence of aneurysm or evidence of vasospasm, compared to 8 patients in those who did not continue it (11% vs. 20%; p=0.05).  

Conclusion
In patients with aSAH ready for discharge prior to completing their nimodipine, we found that nearly half of patients were not prescribed nimodipine at hospital discharge if medically ready for discharge prior to day 14 of hospitalization. We intended to evaluate functional outcomes, but due to a lack of follow-up appointments within the time frame of interest, these data were not available. Future studies with stricter prescribing practices assessing outpatient nimodipine and clinical status would be useful to determine the necessity of a complete course of nimodipine. 

Title: Impact of Adding Abatacept to Antithymocyte Globulin for Acute Graft-Versus-Host Disease Prophylaxis in Matched Unrelated Donor Hematopoietic Stem Cell Transplantation 

Authors: Daniel Wroblewski, PharmD; Carissa Ganihong, PharmD, BCOP; Maribel Pereiras, PharmD, BCPS, BCOP; Simon Gelman, PhD ; Siddhartha Reddy, MD; Michele Lyne Donato, MD

Objective: Compare abatacept and rabbit antithymocyte globulin combination therapy versus rabbit antithymocyte globulin (rATG) acute graft-versus-host disease (GVHD) prophylaxis outcomes in matched unrelated donor hematopoietic stem cell transplantation (HSCT).

Self Assessment Question: (T/F): Abatacept inhibits alloreactive T-cell proliferation and cytokine production while preserving other aspects of immune function.

Background: This study evaluates survival, GVHD, chimerism, and safety outcomes in patients receiving abatacept and rATG combination therapy versus rATG alone for acute GVHD prophylaxis in matched unrelated donor HSCT.

Methods: This single-center, retrospective, observational study included patients undergoing their first allogeneic HSCT from a 10/10 matched unrelated donor for acute myeloid leukemia or myelodysplastic syndrome at Hackensack University Medical Center between January 1, 2019 and December 31, 2024. The primary outcome was GVHD-free, relapse-free survival (GRFS) at 1 year. Secondary outcomes included cumulative incidence of grade 2-4 and grade 3-4 acute GVHD (aGVHD) by day 180 after transplantation, incidence of chronic GVHD (cGVHD) at 1 year, time to neutrophil and platelet engraftment, full donor chimerism at day 30 and day 90 after transplantation, relapse-free survival (RFS) at 1 year, and overall survival (OS) at 1 year. Safety outcomes, including incidence of cytomegalovirus (CMV) and Epstein-Barr virus (EBV) reactivation within the first 100 days post-transplantation, documented adverse reactions to abatacept, and non-relapse mortality (NRM) at day 180 and 1 year, were also evaluated.

Results: 
Among 155 patients, 76 received abatacept and rATG and 79 received rATG alone for GVHD prophylaxis. Bone marrow stem cell source and favorable performance status were more common in the rATG arm, while post-transplant maintenance was more frequent in patients receiving abatacept and rATG. Otherwise, baseline characteristics were similar among groups. At 1 year, GRFS was lower with abatacept and rATG prophylaxis (10% vs 30%, p=0.018), as was NRM at day 180 (1.3% vs 8.9%) and 1 year (6.6% vs 19%, p=0.02). cGVHD by 1 year was higher with abatacept and rATG prophylaxis (mild-severe: 73.2% vs 50.7%, p=0.009; moderate-severe: 38% vs 14.5%, p=0.002). EBV reactivation by day 100 was more common with rATG alone (63.3% vs 30.3%, p=0.0001). 

Conclusion: 
The addition of abatacept to rATG-based GVHD prophylaxis was associated with inferior GRFS at 1 year, driven by a higher incidence of cGVHD.  It was also associated with improved NRM , with similar rates of aGVHD in patients undergoing MUD allogeneic HSCT. Similar results were reported in prior studies where abatacept-based prophylaxis showed benefit in aGVHD, NRM, and relapse, but not cGVHD. Further studies are warranted to clarify the role of abatacept and rATG prophylaxis in this setting.

Evaluation of multidrug-resistant organisms in prolonged cefepime versus levofloxacin use through engraftment in allogeneic stem cell transplant recipients
Harry Grant Woodard, PharmD1, May Aziz, PharmD, BCOP1, Rebekah Dyer, PharmD, BCPS,1 William Clark, MD2, Christina E. Maguire, PharmD, BCIDP, AAHIVP11Virginia Commonwealth University Health System Department of Pharmacy Services 2Virginia Commonwealth University Department of Hematology and Oncology

Learning objective: Audience members will be able to explain the risks and benefits of early de-escalation of antibiotic therapy for neutropenic fever in allogeneic stem cell transplant recipients.

Background: The purpose of this project is to evaluate rates of multidrug-resistant organisms (MDROs) between prolonged cefepime use through allogeneic stem cell transplant (SCT) engraftment versus de-escalation to levofloxacin to help guide clinical decisions.

Methods: This is a single-center retrospective review of SCT recipients from 7/1/23 to 10/2/25. Patients who received prophylactic levofloxacin that was escalated to cefepime at neutropenic fever (NF) onset were included. Exclusion criteria were MDRO within the past 6 months, documented source of infection, and use of gram-negative coverage other than cefepime. Patients were categorized into two groups: early de-escalation (cefepime < 7 days) versus late de-escalation (> = 7 days of empiric therapy). Statistical analyses were performed using JMP software. For normally distributed data, chi-square tests and Fischer’s exact tests were used when appropriate. For non-normally distributed data, Kruskal Willis tests were utilized. A p-value of < 0.05 was considered statistically significant. The primary outcome is rate of MDROs in the early and late de-escalation groups. Key secondary outcomes include rates of repeat NF, graft-versus-host disease (GVHD), repeat admissions, and length of stay.

Results: Forty-two of 125 patients met inclusion criteria. Baseline characteristics were well balanced between groups. There was one documented MDRO infection within each group within 90 days of fever resolution (p = 1.0).  There were higher rates of repeat NF in the early de-escalation group (29.41% vs. 4%, p = 0.0318) ranging from one to eleven days after the initial NF episode. In patients treated for infection within 90 days of NF resolution, there was a numerically higher rate of culture positivity in the early de-escalation group (80% vs. 36.36%, p = 0.0805). Additionally, there was a trend towards higher rates of gut GVHD (41.67% vs 65%, p=.20) in the late de-escalation group.

Conclusions: This study found no difference in MDRO infection between SCT patients with early versus late de-escalation of antibiotic therapy, with low rates overall. Increased rates of repeat NF in the early de-escalation group and numerical increases in gut GVHD in the prolonged therapy group highlight the challenging balance between benefits and risks of prolonged antibiotic therapy after SCT. Larger studies should be completed to further characterize antibiotic stewardship in this population.

Learning Question:
What are the side effects of prolonged broad spectrum antibiotic therapy? Select all that apply.

• Gut GVHD
• Dyspnea
• Clostridium difficile infections 
• Development of multi-drug-resistant organisms 

     The objective of this project is to increase awareness and utilization of the Pharmacy Dose Adjustment Standard Operating Procedure and Veterans Health Information Systems and Technology Architecture (VistA) Chemotherapy Manager Business Rules to promote cost savings within the Veterans Affairs Medical Center. Through pharmacist education and evaluation of current practices, the goal of this project is to enhance appropriate dose rounding of weight based parental medications administered in the outpatient infusion clinic.

     This quality improvement project will consist of three phases including baseline assessment, educational intervention, and post intervention evaluation. The primary outcome is to evaluate change in utilization of the Pharmacy Dose Adjustment Procedure and VistA Chemotherapy Manager Business Rules dose adjustment allowances for weight based parental medications administered in the infusion clinic. A retrospective review of medication orders from the previous six months will be conducted. Data will be collected on weight based parental medications using VistA reporting tools.

     For each medication order, the prescribed dose and corresponding vial size will be analyzed to determine whether the dose was appropriately rounded in accordance with our procedure. The SOP states rounding to 10% for non-chemotherapies ordered in CPRS is appropriate. The SOP states chemotherapeutic agents are not to be followed by the SOP, so orders must follow the VistA Chemotherapy Manager business rules which allow for 5% rounding. Orders will be categorized into no intervention or opportunities for intervention groups.

     Pharmacist education will be provided including a review of the procedure and business rules, guidance on appropriate dose rounding, and emphasis on the importance of following procedures given potential cost savings. Pharmacists will complete a pre-test and a post-test consisting of a patient case to evaluate effectiveness of education. A medication order review will be completed six months post education and will evaluate change in dose adjustment procedure utilization. The secondary outcome is cost savings and will be analyzed using inventory records from our wholesaler.

Abstract 
Importance- Buprenorphine is an opioid based treatment for chronic pain that has less risk associated with abuse, addiction, and other adverse effects due to its unique pharmacologic properties. To our knowledge, there are no studies published that assess buprenorphine’s effect on Pain, Enjoyment, and General activity scores (PEG). This study aims to explore the relationship between buprenorphine initiation for chronic pain and its effect on PEG scores. 
 
Objective- To compare PEG and other scores used by our pain clinic to estimate effectiveness of buprenorphine in improving quality of life metrics related to chronic pain.  
 
Methods- Patients using buprenorphine for chronic pain were first identified using this facility’s PMOP (pain management, opioid safety, and prescription drug monitoring program) dashboard. Patients’ charts were then reviewed to ensure that they had a baseline PMOP score before starting buprenorphine for pain. Selected scores from patients’ initial PMOP data that we felt translated most to improvements in quality of life were then compared to their most recent to assess change since starting buprenorphine. Patients who only had an initial score were given another survey before assessment. Pre and post scores were recorded and subsequently analyzed using a paired t-test.   
 
Results- Our primary endpoint, change in PEG score from baseline to most recent follow-up, showed a statistically significant improvement, as did patient’s perceptions of pain as measured by our UW-CAP-2 portion of our assessment. There was no statistically significant difference between pre and post-buprenorphine scores when assessing sleep quality and self-efficacy related to pain.  
 
Conclusions- Buprenorphine shows significant improvements in quality of life measures not well defined by other studies (to our knowledge). This study lays a foundation for larger studies related to alternative pain measurement metrics related to buprenorphine and improvements in quality of life. 

Title
Evaluation of pneumococcal antibody titer levels in allogeneic hematopoietic stem cell transplant 
 
Authors
Robyn Turner, PharmD; Rebekah Dyer, PharmD, BCPS 
 
Learning Objective  
Develop a plan for subsequent pneumococcal immunizations based on pneumococcal antibody titer levels. 
 
Background/Objective
To determine the number of allogeneic hematopoietic stem cell transplant (HSCT) recipients with protective pneumococcal antibody titer levels of ≥0.35 μg/mL at Virginia Commonwealth University Health System (VCUHS). 
 
Methods
This was a single-center, retrospective, observational project evaluating pneumococcal antibody titer levels from January 2022 to December 2024.  Adult patients who underwent an allogeneic HSCT, received at least one dose of pneumococcal polysaccharide vaccine (PPSV) or pneumococcal conjugate vaccine (PCV), and had at least one pneumococcal antibody titer panel drawn were included.  The World Health Organization defines protective levels as ≥0.35 μg/mL for PCV serotypes, while expert opinion suggests ≥1.3 μg/mL for PPSV serotypes.  At VCUHS, a level of ≥1.3 μg/mL has been considered protective, regardless of the serotype.  Because thirteen of fourteen serotypes in the VCUHS titer panel are contained in PCV20, this project evaluated whether the lower threshold confers protection.  Protective antibody titer levels were defined as 75% (10/13) of serotypes meeting either threshold.  Data were collected from the electronic medical record and the Virginia Immunization Information System.   
 
Results
There were forty-five patients included.  Using antibody titer level threshold of ≥1.3 μg/mL and ≥0.35 μg/mL, 10 patients (22%) and 26 patients (57%) had protective antibody titer levels, respectively (p=0.0024).  One patient had confirmed invasive pneumococcal disease (IPD).  Although the primary objective of patients with protective antibody titer levels at the lower threshold compared to the higher threshold met significance, the small sample size limited the ability to evaluate potential confounding factors associated with meeting the threshold for protective antibody titer levels. 
 
Conclusion(s)
The number of patients with protective antibody titer levels based on the lower threshold of ≥0.35 μg/mL was significant.  This suggests that the lower threshold may be appropriate to confer protection against IPD in patients who underwent an allogeneic HSCT because only one patient had confirmed IPD.  Updating internal guidance documents to define protective antibody titer levels using the lower threshold may be warranted.   
 
Self-Assessment Question 
 
Why was it important to evaluate the lower threshold of ≥0.35 μg/mL in this project? 
 
A. It is the standard used for all pneumococcal serotypes at VCUHS 
B. It is the established threshold for PPSV serotypes
C. Thirteen of fourteen serotypes in the VCUHS titer panel are contained in PCV20
D. It eliminates the requirement for pneumococcal revaccination in HSCT recipients 
 
Disclosures
The authors and contributors have no conflicts of interest to disclose.

Authors: Elise Hildebrandt, PharmD; Sara Bouberhan, MD; Joseph Elijah, PharmD, BCOP, BCPS

Learning Objective: Describe the real-world effectiveness of mirvetuximab soravtansine-gynx (MIRV) ± bevacizumab in patients with platinum-resistant ovarian cancer (PROC) treated at Massachusetts General Hospital (MGH).

Background/Objective: PROC has limited treatment options. MIRV improved outcomes in FORWARD II and MIRASOL, leading to FDA approval for folate receptor alpha (FRα)-high disease. Real-world data remain limited. This study evaluates MIRV ± bevacizumab in PROC at MGH.

Methods: This single-center retrospective case series included adults (≥18 years) treated at MGH with platinum-resistant ovarian, fallopian tube, or primary peritoneal cancer and FRα expression of 25-100%. Eligible patients received MIRV ± bevacizumab with a cycle 1 starting dose ≥ 5 mg/kg using adjusted ideal body weight and routine premedications per the MIRV package insert. Patients enrolled in MIRV clinical trials or who had not received the recommended premedications were excluded. Primary outcomes were progression-free survival (PFS), best overall response (BoR), time on treatment (ToT), and duration of response (DoR); the secondary outcome was overall survival (OS). Baseline characteristics were summarized descriptively. PFS and OS were estimated using Kaplan-Meier methods with log-rank comparisons. BoR, DoR, and ToT were summarized overall and compared between platinum-free interval (PFI) subgroups (<3 vs 3-6 months) using Mann-Whitney U and chi-square tests where appropriate.

Results: A total of 61 patients were included: 3 (4.9%) had FRα expression 25-49%, 7 (11.5%) had 50-74%, and 51 (83.6%) had ≥ 75%. Twenty-four patients (39.3%) had a PFI <3 months and 37 (60.7%) had a PFI of 3-6 months. Median PFS, DoR, and OS were 4.99, 3.04, and 9.66 months. No complete responses were observed; 10 (16.4%) achieved partial response (PR), 24 (39.3%) had stable disease (SD), and 13 (21.3%) had progressive disease (PD). Four patients (7.3%) discontinued due to toxicity. Patients with PFI of 3-6 months had a numerically longer DoR, though this was not statistically significant (p = 0.383). BoR did not differ significantly by PFI (p = 0.876), although more patients experienced PR or SD in the 3-6 month group.

Conclusions: Among patients with platinum-resistant FRα-positive ovarian cancer, MIRV demonstrated modest real-world activity, with lower PFS, BoR, and OS compared to MIRASOL and FORWARD II. Similar to MIRASOL, most patients achieved SD rather than PR despite comparable prior lines of therapy. Although not statistically significant, patients with longer PFI tended to have longer DoR, suggesting potential benefit in this subgroup.

Self-Assessment Question:
Which statement most accurately reflects the real-world outcomes of MIRV in PROC patients at MGH?

• MIRV resulted in high rates of CR with minimal adverse events, and outcomes were comparable across PFI groups
• MIRV demonstrated modest activity with the majority of patients achieving PR or SD
• MIRV showed minimal activity with no disease activity, and most patients discontinued due to toxicity, with significant differences based on PFI
• MIRV led to durable responses in a majority of patients, with OS exceeding 12 months regardless of PFI

Authors 
Joanna Nguyen, PharmD; Annie Jeon, PharmD, BCPS; Lina Saliba, PharmD, BCPS, BCCCP; Jenna Smith, PharmD, BCCCP; Lois Lee, PharmD, BCPPS, BCIDP  
 
Learning objective
Describe how rapid PCR-based MRSA screening helps support antimicrobial stewardship compared to culture-based screening 
 
Background/Objective 
This study aims to compare the impact of rapid PCR-based versus culture-based MRSA screening on antibiotic stewardship outcomes, primarily vancomycin duration of therapy in hospitalized patients. 
 
Methods 
This retrospective chart review compared outcomes between culture-based (May-November 2024) and PCR-based (January-June 2025) MRSA screening following institutional implementation of the latter in December 2024. Eligible patients received at least one vancomycin dose with MRSA screening ordered within 48 hours of vancomycin initiation; patients were excluded for age under 18 years, death or transfer out of the hospital during active therapy, vancomycin for non-MRSA indications, or vancomycin therapy prior to admission. Primary outcome was vancomycin duration (reported as median with interquartile range and analyzed using Mann-Whitney U test); secondary outcomes included test turnaround time, test concordance rates, and vancomycin continuation from the Emergency Department (ED) into hospital admission. 
 
Results 
A total of 167 patients were included. Median vancomycin duration was significantly shorter in the PCR-based group compared to the culture-based group (1 vs. 3 days, p < 0.001). Turnaround time to final result was 5 vs. 29 hours from order entry and 2 vs. 26 hours from specimen collection for PCR-based and culture-based screening, respectively. The majority of test results were true negatives; false positives occurred in 13% of PCR-based and 7% of culture-based screenings. Among 40% of patients who received initial vancomycin in the ED, concurrent MRSA screening was ordered in only 59% (PCR-based) and 33% (culture-based) of these patients. Vancomycin was continued at hospital admission in up to 93% of patients. 
 
Conclusion 
PCR-based MRSA screening significantly reduced vancomycin therapy duration through rapid results and expedited de-escalation. ED screening rates remained suboptimal despite high vancomycin initiation in this population, representing an intervention opportunity. Future directions include expanding this study across the health system, optimizing timing and ordering of screening through standardized ED protocols, and educating clinical staff on PCR-based screening utility for de-escalation. 
 
Self-assessment question:  
Based on the study findings, which of the following statements regarding MRSA screening is most accurate? 
A.  PCR-based MRSA screening significantly reduced vancomycin duration of therapy compared to culture-based screening, because it demonstrated substantially higher true negative rates. 
B. PCR-based MRSA screening significantly reduced vancomycin duration of therapy compared to culture-based screening, primarily due to faster test turnaround time. 
C. PCR-based MRSA screening provided similar vancomycin duration outcomes compared to culture-based screening. 
D. PCR-based MRSA screening significantly reduced vancomycin duration of therapy compared to culture-based screening by decreasing the frequency of empiric vancomycin initiation.

Authors: Kyndal Lemelin, PharmD; Jillian Dann, PharmD, BCPS, BPTXP; Kylea Clark, PharmD; Kathlene DeGregory, PharmD, BCOP

Objective: Appreciate the risk of bone mineral density loss in lung transplant candidates and identify actionable steps to improve transplant bone health management. 

Background / Objective: Lung transplant candidates have high rates of bone loss related to corticosteroids and comorbid factors. This quality improvement project aims to address barriers to guideline-directed therapy and increase pre- and post-transplant GDMT to over 80%. 
Methods: This multidisciplinary QI project will evaluate current practice surrounding bone health management using the Plan-Do-Study-Act (PDSA) framework. QI tools including process mapping, cause-and-effect analysis, and Pareto charting were used to identify gaps in the existing workflow. Baseline data was collected by retrospective chart review for lung transplants performed at UVA Health from January 1 2024 to December 31, 2024 to be compared to post-intervention data. Outcomes of interest included prevalence of osteoporosis and osteopenia, specialist referral and therapy initiation rate, rate of fractures, and follow up bone density scan. Baseline data analysis informed the development of the primary problems list, followed by a multidisciplinary brainstorming of potential solutions. Implementation of the first interventions began in February 2026. New interventions will be introduced monthly, with data analyzed each month to assess impact. 

Results: Baseline analysis identified lower rates of GDMT post-transplant compared with pre-transplant and 18% of patients sustaining a fracture within 1 year. Pareto analysis demonstrated that five drivers accounted for ~80% of care gaps: absence of pre-transplant DEXA, lack of post-transplant DEXA within 1 year, absence of prescriptions for vitamins, lack of pharmacy follow-up, and missing endocrinology visits when indicated. Initial PDSA cycles targeted inappropriate discontinuation of calcium and vitamin D after transplant through pharmacy education and modification of discharge medication reconciliation to ensure continuation of indicated supplements. Interventions are being implemented in two-month cycles with ongoing evaluation.

Conclusion: This QI initiative identified key workflow barriers to guideline-directed bone health management in lung transplant candidates and implemented targeted, multidisciplinary interventions to address them. Ongoing PDSA cycles will evaluate the impact of these and future interventions on screening, treatment, and adverse outcomes rates. This approach may provide a scalable framework for improving bone health optimization in all transplant populations.

Authors





Lucas O’Brien, PharmD; John Hill, PharmD, MS; Eva Acks, CPhT; Lisa Hurowitz, PharmD; Stephen Wu, PharmD; Lauren Taylor, CPhT; Nick Paulson, PharmD, MBA; Richard Ewusie-Monney, PharmD, BCSCP; Samuel Culli, PharmD, MPH; Grace Pak, PharmD, MHA, BCPS; Amanda Stick, PharmD, MPH






Learning Objective





Describe the process of developing pharmacy standard operating procedures to maintain medication distribution during prolonged dispensing system downtimes 






Background/Objective





Critical cyberattacks on healthcare increased 179% from 2017 to 2023. Existing downtime procedures are often insufficient for prolonged outages. This project developed SOPs for an extended dispensing technology downtime at an academic medical center. 






Methods





A stakeholder group of pharmacists/pharmacy managers and pharmacy technician supervisors/information technology specialists was convened to address two downtime scenarios at The Johns Hopkins Hospital: outage of the carousel server or the automated dispensing cabinet (ADC) server of the hospital. For each scenario, the group conducted iterative gap analyses to identify vulnerabilities in dispensing, including order entry, verification, and distribution. Dispensing data was used to characterize unit-level medication volume and inform workflow decisions. Standard operating procedures were developed through a series of stakeholder meetings, with small-scale feasibility assessments of individual policies.






Results





Our gap analysis for carousel downtime identified key challenges. Transferring the carousel stock to manual shelving will require a plan to rapidly obtain an additional 14 shelving units. Without the carousel interface, cart fill and ADC restock labels will need to be manually generated as well as reports for medication purchasing. The gap analysis also revealed vital considerations for an ADC server outage. Inventory management will be complicated by an inability to process automated stockout and restock reports. Controlled substance documentation will also be compromised with cabinets placed into critical override, which must be navigated in consideration of their availability for emergent doses. 






Conclusions





SOP development for pharmacy technology downtime is an inherently creative process requiring diverse operational expertise, dedicated brainstorming time, and organized completion of follow-up tasks from the sessions. The key challenges for the carousel outage were mapping the inventory onto external shelving and planning generation of picklists and labels. An ADC interface outage will require interdepartmental coordination to ensure timely stocking, dispensing, and documentation of medications.






Self-Assessment Question





Which of the following is NOT part of the process for developing a downtime procedure?

• Gap analysis
• Predicting every downtime scenario
• Testing solutions
• Refining solutions

Authors: Emma E. Nelson, PharmD; Lauren M. Hynicka, PharmD, FCCP, BCPS; Jill A. Morgan, PharmD, BCPS, BCPPS, FNAP; Chelsea N. Di Polito, PharmD, BCPP; Gloria M. Reeves, MD; Megan J. Ehret, PharmD, MS, BCPP, FAAPP

Learning Objective: Describe key clinical and patient factors that influence expert recommendations for long‑acting injectable antipsychotic (LAIA) use in pediatric schizophrenia.

Background
Schizophrenia is a chronic psychiatric disorder often emerging in adolescence, with early onset linked to worse outcomes such as cognitive deficits, social dysfunction, and increased relapse and hospitalization. Timely, consistent pharmacologic treatment is key to improving prognosis.

Oral antipsychotics are the standard of care, but pose adherence challenges in pediatric patients, contributing to relapse and higher rates of healthcare use. LAIAs may improve adherence by reducing dosing frequency. Although LAIAs are increasingly used off-label in pediatric patients, they remain unapproved by the U.S. Food and Drug Administration (FDA) for individuals under 18, and supporting evidence is limited to small observational studies and case reports.

Objective
To develop consensus-based recommendations for LAIA use in pediatric schizophrenia, including agent selection and dosing.

Methods
A three‑round Delphi process was conducted using an online survey tool to gather input from physician and pharmacist experts. Experts were identified through guideline authorship, employment at pediatric psychiatric facilities, and participation in professional associations. Eligible participants were required to have at least five years of post‑graduate experience in pediatric psychiatry or to provide care for ten or more pediatric patients with schizophrenia annually, as well as experience recommending LAIAs. The study aimed to recruit a panel of 30 experts. Round 1 consisted of free‑response questions, Round 2 used a Likert‑scale format, and Round 3 presented patient cases to verify the Round 2 findings. Consensus was defined as at least 70% agreement among participants.

Results
Results show consensus on key indicators for LAIA use, including relapse after missed oral doses and patient willingness to receive injections. Experts agreed that established efficacy or tolerability with the corresponding oral agent supports LAIA selection. Consensus was also reached for avoiding certain agents in younger patients or those with extrapyramidal symptom risk. Several clinical factors, including oral overlap strategies and some age‑related considerations, did not reach consensus. 

Conclusions
Experts reached consensus on several key indicators for the use of LAIAs, including relapse following missed oral doses and patient willingness to receive injections. Agreement was also achieved regarding the appropriateness of initiating an LAIA when effectiveness has already been demonstrated with the corresponding oral formulation. However, several areas showed considerable variability and did not reach consensus. This lack of uniformity underscores that many clinical scenarios lack a clearly preferred agent, reflecting the complexity of real‑world pediatric schizophrenia management. Overall, these findings highlight an important need for head‑to‑head comparative trials to better inform LAIA selection in pediatric populations. 

Self‑Assessment Question
Which factor reached expert consensus as strongly supporting the use of a long‑acting injectable antipsychotic in pediatric schizophrenia?
A. Concern for injection volume
B. Patient willingness to receive injections
C. Placement in foster care
D. Age under 14 years

• Title: Effects of long-acting injectable antipsychotics on likelihood of inpatient psychiatric readmission within 90 days
• Authors: Erin M. Seddon, PharmD; Autumn Peck, PharmD, MBA; Stephen Kazmer, PharmD; Anna Marie Fink, PharmD.  
• Objective: Audience members will be able to assess the benefits of Long-Acting Injectable Antipsychotics on readmission rates compared to oral antipsychotics.
• Self-Assessment Question: This study showed a statistically significant difference in readmission rates between those prescribed a long-acting injectable antipsychotic vs those prescribed an oral only regimen (True or False)  
• Methods: A retrospective chart review of patients meeting inclusion criteria was conducted to determine the rate of 90-day readmission, with data collected from August 1, 2022, until July 31, 2025; included patients were at least 18 years of age and had an index psychiatric admission lasting at least 5 days. Patients were excluded if the long-acting injectable received was intramuscular naltrexone, had a sole diagnosis of any substance use disorder, and/or a diagnosis of dementia or a dementia related disorder. The primary outcome of 90-day psychiatric readmission was analyzed using a Chi-Square test for large sample nominal data. Secondary outcomes (ED presentation within 90 days; differences in rate of ED presentation or admission between LAIAs) were evaluated using an unpaired T-test to normal distribution interval/ratio data. Baseline characteristics and other confounding variables were compared between groups and evaluated using descriptive statistics.
• Results: Investigators observed a lower rate of 90-day psychiatric readmissions in patients prescribed a LAIA vs. those prescribed an oral only regimen, with readmission rates of 20% vs. 24%, (p=0.629).  Mean time to readmission was observed to be lower in the LAIA group (22 days) vs the oral only group (37 days), showing a shorter time to readmission in those prescribed a LAIA. Of the six LAIA studied, four agents were found to have associated readmissions, with Abilify Maintena and Uzedy having no associated readmissions. A lower rate of 90-day ED presentations was seen in the LAIA group vs the oral group with rates of 10% vs 12% respectively, (p= 0.749). Mean time to ED presentation was observed to be 17 days in both groups
• Conclusion: Investigators saw a non-statistically significant lower rate of 90-day readmissions and ED presentations with LAIAs. Two of the LAIA studied had no readmissions. Further research is needed regarding the incidence of 90-day readmissions between LAIA and oral only regimens, as well as the impact of demographic factors on readmission. Widespread education on the benefits of LAIAs is indicated to allow for less prescriber hesitation and generate greater evidence for future studies.

Title:
Improving SGLT2 inhibitor prescribing at discharge in patients with HFrEF

Authors:
Lotanna Ezeofor, PharmD; Stephie Ikama, PharmD Candidate; Pavel Goriacko, PharmD, MPH; Angela Cheng, PharmD, BCPS, FASHP

Objective:
To increase the rate of SGLT2 inhibitor prescriptions at hospital discharge to ≥70% among eligible patients with heart failure with reduced ejection fraction.

Self Assessment Question:
Which intervention is most effective in improving SGLT2 inhibitor prescribing at discharge for eligible patients with HFrEF?

Background:
Sodium-glucose cotransporter 2 inhibitors are guideline-directed medical therapy for HFrEF and have demonstrated reductions in mortality and heart failure hospitalizations. Despite increased inpatient initiation following formulary addition and electronic order set implementation, discharge prescribing remains suboptimal, highlighting a gap in transitions of care.

Methods:
This performance improvement project will use a Plan-Do-Study-Act framework at a large academic medical center. A retrospective chart review will identify eligible HFrEF patients and evaluate baseline discharge prescribing rates and barriers. Targeted interventions, including electronic medical record enhancements, provider education, and workflow modifications, will be implemented and assessed for their impact on prescribing rates.

Results:
Data collection and analysis are ongoing. We anticipate identifying key barriers to discharge prescribing and expect that implementation of targeted interventions will improve prescribing rates toward the institutional goal. Final results will be presented.

Conclusion:
This initiative aims to improve adherence to guideline-directed medical therapy at discharge and strengthen transitions of care. Findings may support scalable strategies to optimize SGLT2 inhibitor prescribing and improve outcomes in patients with HFrEF.

Authors: Kaitlyn Healy, PharmD; Siu Yan (Amy) Yeung, PharmD, BCCCP; Clement Ng, PharmD, CAHIMS; Brian Grover, PharmD, BCPS; Hyunuk Seung, MS 
Learning Objective: Describe the feasibility of utilizing a large language model (LLM) to analyze clinical interventions completed by pharmacists and assign appropriate categorization.   
Background/Objective: The goal of this study is to use a LLM software to sort pharmacist interventions into predefined categories determined by the research team and compare the interrater reliability of sorting completed by the LLM compared to that of a pharmacist.
Methods: This retrospective study evaluated pharmacist interventions documented within the electronic health record (EHR). Completed pharmacist interventions include both structured fields and free-text documentation. Interventions were extracted from the EHR, de-identified, and a random sampling was selected for inclusion. Selected interventions were categorized by both the research team and a large language model (LLM). The LLM used in this study, GPT-5 accessed via the Microsoft Copilot™ interface, was adapted using structured prompt engineering to simulate pharmacist clinical reasoning. Retrieval-augmented generation (RAG) was incorporated to support predefined categorization of interventions. Inter-rater agreement between the research team and the LLM will be assessed using weighted Cohen’s kappa analysis. A total of 852 interventions will be analyzed based on a power calculation targeting a kappa of 0.70.  
Results: Overall, 889 interventions were included. All 13 categories were used by both the LLM and the pharmacist reference standard. Interventions received a mean of 1.23 labels and a median of 1, though 185 pharmacist-reviewed and 168 LLM-reviewed interventions were assigned multiple labels. Primary category agreement between the LLM and the reference standard was substantial (κ=0.70; 95% CI: 0.67–0.74), closely aligning with inter‑pharmacist agreement (κ=0.72; 95% CI: 0.69–0.76). Multi‑label agreement was similarly strong, with Jaccard similarity of 0.76 for LLM vs reference and 0.77 for pharmacist vs pharmacist, alongside low Hamming loss and no consistent pattern found regarding category‑level variability.
Conclusions:  LLM performance in classifying pharmacist interventions aligned with human classification, with substantial agreement seen on primary categorization and multilabel alignment. These findings support the potential use of LLMs for pharmacist intervention classification tasks. 
Self-Assessment Question:  

• Which of the following describes the purpose of using a large language model in this study?  

• To replace pharmacist clinical decision making.  

• To generate new pharmacist interventions.  

• To categorize completed pharmacist interventions.  

• To standardize documentation of pharmacist interventions.  

Authors: Seo Young Chun, PharmD; Melissa Chaung, PharmD, BCPS; Michael A. Wynd, PharmD, BCPS

Learning Objective: At the conclusion of my presentation, the audience will be able to compare the allograft function outcomes of early vs late conversion from tacrolimus to belatacept in kidney transplant recipients. 

Background/Objective:
Assess the impact of timing of conversion from tacrolimus to belatacept on allograft function in kidney transplant recipients (KTRs).

Methods:
This was a single-center, retrospective cohort study evaluating first kidney-alone, adult (age ≥ 18 years at the time of conversion), Epstein-Barr virus IgG seropositive KTRs who converted from tacrolimus to belatacept between January 1, 2013, and December 31, 2024. Recipients of multi-organ transplants or patients receiving belatacept for < 30 days were excluded. Outcomes at 1-year post-conversion were compared between KTRs who converted early (< 6 months post-transplant) vs late (≥ 6 months post-transplant). The primary endpoint was the change in estimated glomerular filtration rate from baseline. Secondary endpoints included patient and allograft survival, biopsy-proven acute rejection, opportunistic viral infections, malignancy, discontinuation-rate of belatacept, and adverse events. Demographic data, within-cohort, and between-cohort comparisons were analyzed using appropriate statistics.

Results:
Of 177 patients screened, 76 patients were included, with 67 patients in the early conversion group and 9 patients in the late conversion group. Baseline demographics were similar between groups, although pre-transplant donor-specific antibodies were more common in the late conversion group (44.4% vs 11.9% [p = 0.04]). Median eGFR at conversion was lower in the early conversion group compared to the late conversion group (20 vs 45 mL/min/1.73m2 [p = 0.01]). At 1 year post-conversion, the early conversion group demonstrated a greater change in eGFR (23 vs 7 mL/min/1.73m2 [p = 0.0083]). No significant differences were observed in patient and allograft survival, rejection, opportunistic infections, and belatacept discontinuation between groups. 

Conclusion:
Early conversion from tacrolimus to belatacept was associated with greater improvement in eGFR, likely reflecting lower baseline eGFR and greater opportunity for recovery at the time of conversion. While interpretation is limited by the disproportionately smaller late conversion cohort, this study provides descriptive real-world data on institutional belatacept conversion practices and outcomes across different conversion strategies.

Self-Assessment Questions:
Which of the following is a common reason for patients to convert from tacrolimus to belatacept?

1. Nephrotoxicity
2. Gastrointestinal side effects
3. Neurotoxicity
4. All of the above

Title: Evaluation of guideline-directed venous thromboembolism prophylaxis in high-risk ambulatory cancer patients
Authors: Srivishnu Vardhan Parasaram, PharmD; Julie Shupp, PharmD, BCOP; Jorge Aguilera, PharmD, BCPS
Learning Objective: Audience members will be able to evaluate institutional adherence to NCCN/ASCO guideline-directed venous thromboembolism (VTE) prophylaxis in ambulatory cancer patients.
Background/Objective: Cancer-associated thrombosis is a significant cause of morbidity and mortality in oncology patients. The National Comprehensive Cancer Network (NCCN) and American Society of Clinical Oncology (ASCO) guidelines recommend consideration of VTE prophylaxis for high-risk ambulatory cancer patients initiating systemic chemotherapy, defined by a Khorana Score of 2 or greater. This study aimed to determine the rate of appropriate VTE prophylaxis prescribing at John R. Marsh Cancer Center within Meritus Health and to evaluate associated clinical outcomes.
Methods: This retrospective observational study evaluated adults aged 18 and older presenting with a new cancer diagnosis and initiating chemotherapy at John R. Marsh Cancer Center between January 1, 2024 and December 31, 2024. Baseline Khorana Scores were calculated to stratify VTE risk. Patients were excluded if they were receiving therapeutic anticoagulation for a pre-existing condition (e.g., atrial fibrillation, secondary prophylaxis), had a documented absolute contraindication to anticoagulation, were pregnant, or received treatment exclusively at an outside facility. The primary outcome was the rate of appropriate VTE prophylaxis prescribing based on NCCN guidelines. Secondary outcomes included the incidence of VTE events, major bleeding events, and all-cause mortality, stratified by Khorana Score, management appropriateness, and metastatic status.
Results: A total of 167 patient charts were included for analysis. Guideline-adherent VTE prophylaxis management was observed in 67.1% of patients (n=112), with 55 patients (32.9%) managed inappropriately based on their baseline Khorana Score. Of the entire cohort, only 3 patients (1.8%) were prescribed pharmacologic thromboprophylaxis, reflecting a very low overall prescribing rate despite the high proportion of high-risk patients. VTE events occurred in 9.8% (n=11) of appropriately managed patients compared to 25.5% (n=14) of inappropriately managed patients, a statistically significant difference (p=0.015; RR 2.60, 95% CI 1.27–5.33). Patients with a Khorana Score ≥2 experienced VTE at a rate of 24.6% compared to 10.0% in low-risk patients (p=0.023; RR 2.46, 95% CI 1.19–5.06). Major bleeding events occurred in 3.0% of the overall cohort (n=5); no statistically significant differences were observed across any subgroup, though the analysis was limited by the low event count. All-cause mortality occurred in 24.0% of the cohort (n=40), with significantly higher rates observed in patients with a Khorana Score ≥2 (36.8% vs. 17.3%, p=0.009) and in inappropriately managed patients (38.2% vs. 17.0%, p=0.005).
Conclusion: Adherence to NCCN/ASCO VTE prophylaxis guidelines at our institution was 67.1%, with an overall pharmacologic prophylaxis prescribing rate of only 1.8%, suggesting that guideline-concordant management in this population is largely driven by appropriate withholding of prophylaxis in low-risk patients rather than active prescribing in high-risk patients. Inappropriately managed patients experienced significantly higher rates of VTE, demonstrating the clinical consequences of non-adherence. All-cause mortality differences across subgroups likely reflect underlying cancer burden and disease severity rather than VTE-attributable death, as cause of death was not captured. While provider hesitance regarding anticoagulation is understandable given bleeding risk and potential treatment delays, this study highlights a meaningful quality improvement opportunity. The occurrence of VTE in low-scoring patients and variable outcomes among high-scoring patients also suggest the Khorana Score alone may have limited precision in this population, underscoring the need for prospective evaluation and potentially more individualized risk stratification tools.