2026 Eastern States Conference

Background/Objective: Midazolam and haloperidol are commonly used for pre-MRI
sedation despite being on the Beers list. The objective of this study is to compare
the efficacy and safety of these medications for pre-MRI sedation in older adults.
Methods: This was a retrospective cohort study from 09/2024 to 01/2026. Patients
were included if they were 65 years or older and ordered pre-MRI sedation through
an order set. Patients were excluded if they had an allergy or intolerance to
benzodiazepines or haloperidol, if they used midazolam or haloperidol 2-24 hours
prior to MRI, if there was deviation from the order set, if they had an anesthesia
consult, or if they were admitted to an intensive care unit (ICU) at the time of MRI. An
MRI was successful if it was completed on the first attempt without use of an
alternative sedation agent. The primary safety outcome was a composite of any of
the following within 24 hours after the pre-MRI sedation agent: fall, intubation or
escalating supplemental oxygen requirement, rapid response team called, use offlumazenil, ICU admission, or death. Chi-square or Fisher’s exact test was used to
compare incidence of MRI success and safety events between midazolam and
haloperidol groups.
Results: There were 39 patients in the haloperidol arm and 81 patients in the
midazolam arm. There was no statistical difference in MRI success between
haloperidol (69.2%) and midazolam (72.9%) [p=0.681]. The primary safety outcome
occurred more frequently in the midazolam arm (30.7% vs. 2.6% (p=0.0002)). New or
escalating use of supplemental oxygen occurred in 21 midazolam patients (25.9%).
Conclusion: No difference in efficacy was observed between haloperidol and
midazolam for pre-MRI sedation in older adults, however, the sample size did not
meet pre-specified power. Midazolam was associated with a higher incidence of
new or escalating oxygen requirement. The use of supplemental oxygen should be
further investigated to determine the clinical significance of this finding.

Title: Ironing Out the Risk: Bleeding Outcomes with Intravenous Iron in Anticoagulated Patients with Heart Failure and Reduced Ejection Fraction (HFrEF)

Authors: Haoxin Liu, PharmD; Kristen Goodrich, PharmD, BCCP; Tania Ahuja, PharmD, FACC, BCCP, BCPS, CACP; Morris Jrada, MD

Objective: Participants will be able to describe the impact of Intravenous (IV) iron on bleeding events in patients with heart failure with reduced ejection fraction (HFrEF) and concomitant anticoagulation usage.

Self Assessment Question: IV iron administration in HFrEF patient with AC use is associated with

• Increased bleeding events
• Higher mortality
• Increased hospital length of stay
• Decreased bleeding events
• None of the above.

Background: HFrEF patients often have comorbidities requiring anticoagulation. While IV iron improves functional status, its impact on mitigating bleeding risk remains unknown. We hypothesize that IV iron reduces bleeding risk in anticoagulated HFrEF patients.

Methods: This was a multi-site retrospective cohort study of hospitalized adults (≥18 years) with HFrEF on anticoagulation and iron deficiency anemia (hemoglobin (Hgb) <13.5 g/dL; ferritin <100 mg/dL or 100–299 mg/dL with transferrin saturation (TSAT) <20%). Patients receiving IV iron were compared to those who did not. Exclusion criteria were receipt of <500 mg IV iron, infective endocarditis or sepsis, active bleeding, iron allergy, pregnancy, dialysis, use of erythropoiesis-stimulating agents or blood transfusions, and loss to follow-up. The primary outcome was a composite of international society of thrombosis and haemostasis (ISTH) major, clinically relevant non-major, and minor bleeding within 6 months. Secondary outcomes included 30- and 90-day readmission, and ferritin, TSAT, and hemoglobin at 1, 3, and 6 months. Electronic health records were reviewed for patient characteristics. Research Electronic Data Capture was used for data collection and SPSS software was used for data analysis.

Results: A total of 223 patients were included (IV iron n=111; no iron n=112). The cohort was 73 [62-82] years, 65% male, 52% white. Median EF was 25 [20-35]% and baseline Hgb was 11.2 [9.7-12.8] g/dL. Apixaban was the most used anticoagulant (n =165,74%), primarily for atrial fibrillation (n =180, 83%). At 6 months, ferritin and TSAT increased by 52.9 ng/dL and 10.5% with IV iron vs. -0.3 ng/dL and 7.5% without. The primary outcome of bleeding occurred in 34.2% in the IV iron group vs. 54.5% in the no iron group (p=0.002). Major bleeding occurred in 1 (0.9%) patient in the IV iron group vs. 6 (5.6%) patients in the no IV iron group. No differences were observed in 30- or 90-day readmissions or mortality rates, or in adverse events between groups.

Conclusion: We found a decreased risk of bleeding events in patients with HFrEF and anticoagulation with the receipt of IV iron compared to those that did not receive IV iron, without an increase in adverse outcomes over a 6-month follow-up period. Further studies are warranted to determine whether these findings are generalizable to HFpEF or general patients without heart failure, and to assess the durability of this effect over longer follow-up durations.

Authors 
Nakayalla Langley, PharmD, MS; Cara Goode, PharmD
 
Objective 
At the conclusion of my presentation, the participant will be able to describe clinician directed nudges and barriers to adoption of a nudge at a Veterans Affairs medical center.

Self-Assessment Question: 
Which of the following are considered nudges?

Background
To increase SGLT-2i prescribing in patients with type 2 diabetes mellitus and atherosclerotic cardiovascular disease, chronic kidney disease, or heart failure by having prescribers sign up for automated messages containing potential candidates.

Methods 
The prescriber directed nudge utilized was an already developed and available report that offers a subscription to automated instant messages and e-mails that are delivered directly to the prescriber once a week. The messages contain a link to a report that provides a list of patients scheduled in their clinic in the next week that are potential candidates for an SGLT-2 inhibitor. Subscribing to the report was not required and could only be done by the prescriber themselves. The prescribers contacted and asked to subscribe to the report included primary care providers, clinical pharmacist practitioners, and cardiology practitioners. Prescribers were communicated with through different formats, including e-mail (group and individual), instant message, in person, and video call.

Results
Between September 2025 and March 2026, nineteen prescribers were contacted about the clinical nudge alerts. Seven providers signed up for the clinical nudge alerts. Two of the seven prescribers were contacted three times before subscribing, and three of the seven were contacted two times before subscribing. Based on the feedback survey, two providers responded and indicated that the nudge system is beneficial to their practice and
integrates well into their workflow. The feedback also revealed that providers expressed the intention to either prescribe empagliflozin or make no change to their current treatment approach. In September 2025, there were 901 veterans with type 2 diabetes mellitus and atherosclerotic cardiovascular disease, chronic kidney disease, or heart failure eligible for an SGLT2i. As of March 2026, that number has decreased to 832 veterans. 

Conclusion
This SGLT2i automated alert was associated with an increase in SGLT2i prescriptions for some prescribers but not for all. The longer a prescriber was subscribed to the SGLT2i automated alert did not seem to have an impact on whether their SGLT2i prescribing increased or decreased, however some prescribers had been subscribed to the nudge for a much longer time period than others. If a clinical nudge requires prescribers to have to opt in and sign themselves up, utilization of the nudge may not be great. Nudges that require a prescriber to voluntarily subscribe themselves via navigating a dashboard type tool may also require multiple contact attempts to the prescriber to get them to subscribe as well as direct one-on-one guidance from an individual to get them signed up.

Title: Evaluating the Impact of Targeted Medication Review on Anticholinergic Medication Prescribing in Patients with Psychosis

Authors: Eva Shkreta, PharmD; Rebecca Bourgery, PharmD, BCPP, BCPS; Caralyn Granato, PharmD, BCPP, BCPS

Presentation objective (for CE credit): At the conclusion of my presentation, audience members will be able to describe the impact of anticholinergic burden in patients with psychosis. 

Self-assessment question: What is the clinical significance of anticholinergic burden in patients with psychosis? 

1. Blocks absorption of atypical antipsychotics
2. Significantly increases risk of cognitive impairment 
3. Main cause of tardive dyskinesia
4. Primary driver of metabolic syndrome

Background:
This project aims to reduce anticholinergic burden (ACB) in patients with psychosis followed by the Health Integration Program (HIP), a specialty team serving patients with psychotic disorders, through targeted medication reviews (TMR).

Methods:
Behavioral health ambulatory care pharmacists completed a TMR for all patients 18 years and older who are served by the HIP team at Cambridge Health Alliance (CHA). TMRs included a review of all anticholinergic medications the patient was prescribed, ACB score, and recommendations for potential deprescribing. A retrospective chart review was conducted at least three months after TMRs were completed. Patients not engaged with a HIP team prescriber or who were hospitalized at the time of chart review were excluded. Primary outcomes included the change in average number of anticholinergic medications and average ACB score after the TMR. Secondary outcomes included anticholinergic prescribing patterns to identify opportunities for intervention, subgroup analyses, and the number of referrals to behavioral health ambulatory care pharmacists. Subgroup analyses to include patients aged 65 years and older, prescribed clozapine, and the use of two or more high-risk anticholinergic medications.

Results: 
A total of 215 TMRs were completed and 206 met the inclusion criteria at the time of data collection. The average ACB score increased by 0.14 from 4.21 three months after the TMRs, with a decrease observed in 8.7% of patients. The average number of medications with ACB increased by 0.06 from 2.52 per patient, and 7.8% of patients had fewer anticholinergic medications. 

TMRs led to 42 medication changes, including 20 discontinuations and 22 dose reductions. Additionally, TMRs resulted in 7 new referrals to ambulatory behavioral health pharmacists. Among this patient group, the anticholinergic medications most frequently prescribed were clozapine, followed by olanzapine, benztropine and quetiapine.

Conclusion: 
Following TMR completion, both average ACB score and number of ACB medications increased. Based on these results, TMRs may not be the most effective tool to reduce anticholinergic burden. Finding alternative interventions to reduce anticholinergic burden is especially critical for patients with psychosis.

Title: Safety of reduced lead-in dosing of apixaban for the treatment of acute venous thromboembolism (94 characters)

Authors: Kira Babinetz, PharmD; Matthew Schwarztrauber, PharmD; Kristen Franklin, PharmD, BCCCP; Vanessa Markle, PharmD, BCPS; Mary Margaret Bliss, PharmD, BCPS (151 characters)

Learning Objective: Describe the incidence of major bleeding associated with reduced versus full-lead in dosing of apixaban following extended parenteral anticoagulation for venous thromboembolism.

Objective: This study aims to evaluate the difference in major bleeding rates between reduced and full apixaban lead-in groups after use of at least 24 hours of parenteral anticoagulation. (176 characters)

Self-assessment question: Which of the following outcomes is true based on the data presented
Which of the following outcomes is true based on the data presented:
A. There was a statistical difference noted in bleeding between the reduced and full lead-in groups
B. There was not a statistically significant difference for the length of stay in the full lead-in group  
C. Mortality and readmission rates were not similar amongst the two groups
D. There was not a statistical difference noted in bleeding between the reduced and full lead-in groups

Methods: This multi-center, single health system, retrospective cohort study included adult patients who received treatment for acute venous thromboembolism with at least 24 hours of parenteral anticoagulation prior to the initiation of apixaban. Patients received either reduced lead-in apixaban dosing of 10 mg twice daily for less than 7 days or full lead-in apixaban dosing of 10 mg twice daily for 7 days, followed by maintenance dosing of 5 mg twice daily. The primary outcome assessed was major bleeding within three months as defined by International Society on Thrombosis and Hemostasis criteria. Additionally, secondary endpoints included all-cause mortality at three months and readmission within 30 days. A subgroup analysis was conducted based on age, body weight, and renal function. (788 characters)

Results: Of 2,836 patients identified, 777 were assessed and 451 met inclusion criteria, including 95 in the reduced lead‑in group and 356 in the full lead‑in group. Median duration of parenteral anticoagulation was longer with reduced lead‑in dosing (88.3 hours [IQR 59.7–142.7]) versus full lead‑in dosing (62.5 hours [IQR 45.5–103]; p<0.001). Major bleeding occurred in 10 patients (10.5%) in the reduced lead‑in group and 30 patients (8.4%) in the full lead‑in group (OR 1.28; p=0.52). Median length of stay was greater in the reduced lead‑in group (6.3 days [IQR 4.1–14.9] vs 5.3 days [IQR 3.1–10.0]; p=0.008). Three‑month mortality and 30‑day readmission rates were similar between groups. (686 characters)

Conclusion(s): No statistically significant difference in major bleeding was observed between full and reduced lead‑in dosing strategies. Reduced lead‑in dosing was associated with a significantly longer hospital length of stay. Mortality at 3 months and 30‑day readmission rates were comparable between groups. Further research is necessary to support safer, more evidence-based clinical decision making when transitioning from parenteral to oral anticoagulation. (450 characters)

Feasibility and impact of an area under the curve-guided dosing protocol of aminoglycosides using Bayesian modeling software among adult and pediatric hospitalized patients
Authors: Madeiline Osborn, PharmD; Craig Worby, PharmD; Rebecca Wang, MD; Jeffrey Low, PharmD; Julie Ann Justo, PharmD, MS
Learning Objective: Understand the benefits of AUC-guided aminoglycoside dosing compared with traditional dosing methods.
Objective: The primary objective is to assess feasibility of AUC-guided dosing compared with prior methods, as measured by pharmacist-reported surveys. Secondary objectives include comparing clinical outcomes before and after implementation.
Methods: This study, using a mixed-methods design, is a retrospective, observational cohort study of hospitalized adult and pediatric patients treated with aminoglycosides between November 2024 and June 2026, with pharmacist surveys to assess feasibility of these processes administered pre- and post-implementation. Survey responses will be summarized using descriptive statistics, and pre- and post-implementation results will be compared to evaluate changes in feasibility, ease of use, and satisfaction.
Results: Results are pending as the study is being conducted.
Conclusions: This study is expected to clarify the feasibility and clinical impact of implementing AUC-guided aminoglycoside dosing at a tertiary medical center, informing antimicrobial stewardship and institutional policy.
Self-Assessment Question: 
True or False: AUC-guided dosing provides a pharmacokinetic approach that measures total drug exposure over time and may offer a more accurate method for optimizing aminoglycoside therapy

Title
Improving Baseline and Routine Monitoring for Valproic Acid and Derivatives
Authors
Sophia C. Villa, PharmD; Julia P. Last, PharmD
Learning Objective 
Audience members will be able to identify optimal monitoring parameters and intervals to support best practices and improve outcomes in patients initiating valproate.
Background/Objective
Valproate can be associated with hepatotoxicity, blood dyscrasias, fetal harm, and serum-level toxicity. This project evaluates the outcome of pharmacist led education focused on adherence to valproate monitoring parameters.
Methods
This retrospective chart review evaluated valproate (VPA) management at three hospitals by assessing deviations from recommended monitoring intervals before and after pharmacist led provider education and standardization of monitoring guidelines. Patient electronic medical records were reviewed in two phases: pre-implementation (July 2022–July 2025) and post-implementation (January–April 2026). Collected data includes patient demographics, serum VPA levels, liver function tests (LFTs), and complete blood count (CBC) components. Patients were included if they were initiated on VPA during admission and maintained therapy for at least six months. Patients started before admission, with short stays, or who discontinued therapy early were excluded. Laboratory monitoring completion rates were then compared between pre- and post-intervention cohorts, which consisted of different, non-matched patient populations.
Results
During pre-implementation, 51 patients were analyzed. VPA levels were obtained in 28 (54.9%) within 2 weeks of initiation or dose change, 33 (64.7%) at 3 months, and 31 (60.8%) at 6 months; none exceeded the upper threshold (125 mcg/mL). LFT monitoring occurred in 48 (94.1%) at baseline, 18 (35.3%) within 2 weeks, and 20 (39.2%) at 3 months. CBC monitoring occurred in 49 (96.1%) at baseline, 22 (43.1%) within 2 weeks, and 24 (47.1%) at 3 months. Post-implementation preliminary data include 5 patients: VPA levels were monitored in 3 (60%) within 2 weeks and at 3 months. LFTs and CBCs were obtained in 3 (60%) at baseline and within 2 weeks; no patients have yet reached the 6-month follow-up. Data collection is ongoing; results may be updated.
Conclusion
Adherence to recommended monitoring for valproate requires stronger evidence to define optimal timing for serum levels, LFTs, and CBCs. Our findings highlight opportunities for pharmacists to ensure proper monitoring practices and improve provider education. Timely serum valproate measurements may enable earlier detection of treatment failure or toxicity, while routine LFT and CBC monitoring can identify adverse reactions sooner, allowing prompt intervention and reducing risk to patients.
Self-Assessment Question
When should serum valproate levels be checked after initiation of therapy or dose adjustment?

Authors: Matthew Schwarztrauber, PharmD; Kira Babinetz, PharmD; Kristen Franklin, PharmD, BCCCP; Vanessa Markle, PharmD, BCPS; Mary Margaret Bliss, PharmD, BCPS

Learning Objective: Describe the rates of recurrent venous thromboembolism in reduced lead-in and full lead-in dosing of apixaban following extended courses of parenteral anticoagulation for the treatment of venous thromboembolism.

Self-Assessment Question: No statistically significant difference was found in recurrent venous thromboembolism rates between the reduced lead-in and full lead-in apixaban dosing groups. True/False

Background/Objective: Compare the rates of recurrent venous thromboembolism (rVTE) within 3 months for full versus reduced apixaban lead-in dosing in patients who had an extended duration of parenteral anticoagulation for the treatment of venous thromboembolism (VTE).

Methods: Multi-center, single health system, retrospective cohort study conducted using electronic health record data. Adult patients who received 24 hours or more of parenteral anticoagulation before starting apixaban for VTE treatment were included. Patients were excluded if they had a history of heparin‑induced thrombocytopenia, a documented clotting disorder, were receiving anticoagulant therapy, or underwent mechanical thrombectomy or fibrinolytic treatment during the initial diagnosis encounter. The two study groups were the reduced lead‑in group (less than 14 doses of apixaban 10 mg) and the full lead‑in group. The primary outcome was the incidence of rVTE within three months of apixaban initiation. Secondary outcomes included length of stay, 3-month all-cause mortality and 30-day readmission.

Results: A total of 2836 patients were identified. Of the 777 patients evaluated for inclusion, 95 and 356 patients were included in the reduced lead-in and full lead-in groups, respectively. Statistically significant differences existed between groups in the following baseline characteristics: age, weight, renal function, and total hours of parenteral anticoagulation. The reduced lead-in group had zero instances of rVTE while full lead-in group had six (p=0.20). The median length of stay was one day longer in the reduced lead-in group (6.3 v. 5.3 days, p=0.008). No significant difference was found between groups for 3-month mortality or 30-day readmission. Due to incomplete data collection, power was unable to be assessed.

Conclusion: The findings of this study do not show a significant difference in rVTE incidence between reduced and full lead-in dosing of apixaban at three months following extended durations of parenteral anticoagulation for treatment of VTE. The validity of this study is limited by incomplete data collection. Future completion of data collection may increase the study's validity.

Title: Care bundle to improve outcomes for patients with hepatic encephalopathy
 
Authors: Emily Baraclough, PharmD, Deslynne Henkel, PharmD, Jennifer Szwak, PharmD, BCPS, FCCP; Madison McKnight, PharmD, BCPS; The Johns Hopkins Hospital, Department of Pharmacy, Baltimore, MD 

Learning Objective: Define current management practices and readmission rates for patients with hepatic encephalopathy at the Johns Hopkins Hospital (JHH).  

Background/Objective: Hepatic encephalopathy (HE) is associated with significant healthcare utilization and costs. This study aims to characterize the HE population and current readmission rates at JHH to later develop a consensus-driven care bundle to improve management and reduce readmissions. 

Methods: This quality improvement study includes two phases. First, a retrospective cohort analysis included adult patients admitted to JHH from 2022-2024 with a primary diagnosis of hepatic encephalopathy. This characterized demographics, disease severity, medication use, transitions-of-care practices, and 30- and 90- day readmissions. Patients receiving a liver transplant within 30 days of discharge or death within 30 days of discharge were excluded. Data was collected via the Precision Medicine Analytics Platform (PMAP), an electronic health record-derived database, and manual chart review. Descriptive statistics summarized baseline characteristics and care patterns, as well as readmission rates. A follow-up study will utilize a Delphi model with JHH hepatologists to achieve consensus on key interventions and develop a standardized care bundle. 

Results: A total of 221 patients were included in the study. Alcohol-related cirrhosis was the most common etiology (37.7%), followed by mixed etiologies (15.9%) and metabolic-associated cirrhosis (15.3%). The cohort was predominantly male (51.8%), with a mean age of 57.35 ± 12.96 years. The mean MELD score at the time of dialysis was 27.84 ± 6.22. Prior to admission, lactulose was prescribed in 31.82% of patients, while rifaximin was prescribed in 26.36%. Among patients not receiving rifaximin prior to admission, 27.3% had a prescription initiated at discharge, of whom 8.64% completed a prior authorization before discharge. The 30-day readmission rate was 17.2%, while the 90-day readmission rate was 27.1%. 

Conclusion: In this cohort of patients with cirrhosis and hepatic encephalopathy, variability in pre-admission use and discharge access to guideline-directed therapy was observed. Inconsistencies in rifaximin initiation and prior authorization completions highlight opportunities to optimize transitions of care and reduce readmissions through targeted interventions.  

Learning objectives: Audience members will be able to determine if Balfaxar or KCentra is superior in achieving hemostasis in different types of bleeds; brain, gastrointestinal, and other.
Authors: Allison Carmean, PharmD, Jesse Dorchak, PharmD, BCPS; Thomas Simunich, MS, MBA; Jacob Allenbaugh, DO; Lauren DeLong, DO; Shawna Morrissey, DO
Background: Limited research exists on the efficacy of 4-factor Prothrombin complex concentrates (4F-PCCs) to reverse bleeds caused by Warfarin and DOAC use. This study aims to compare the efficacy of Balfaxar or KCentra to reverse various types of bleeds.
Methods: This study is a retrospective study comparing pre/post measures for patients who received KCentra from February 2022 to February 2024 and Balfaxar from March 2024 to March 2026 at CMMC. Initial fixed dosing for both agents consisted of 2,000 units for DOACs and 1,500 units for Warfarin. Supplemental dosing used actual body weight and patients that received supplemental doses have been excluded. Hemostasis will be defined on the CT scan after Balfaxar or KCentra is given to ensure bleeding has stopped and if the lab values below return to normal. Lab values for hemostasis included INR less than 1.5, PT 11-13 seconds, aPTT 25-40 seconds, platelets 150,000-300,000, Hgb > 7, and fibrinogen 200-400. A 6 hour post CT scan was also used to ensure hemostasis was achieved. The analysis of the statistics will be processed and presented at Eastern States.
Results: Results will be presented at Eastern States.
Conclusion: Conclusion will be presented at Eastern States.

Title: Prescribing Trends and the Risk of Serotonin Syndrome in Patients Receiving Linezolid and Serotonergic Medications

Authors: Clara Bishay, PharmD, MSMEd; Eric Kowalek, PharmD, BCPS; Danielle Kuhn, PharmD, BCPS

Learning Objectives:
Audience members will be able to:

1. Identify the risk of serotonin syndrome (SS) based on the existing literature.
2. Describe the prescribing trends of the most commonly reported serotonergic agents (SAs) administered with linezolid and the associated risk of serotonin syndrome.
3. Outline key study limitations, clinical significance, and areas for future research.

Methods: This retrospective, descriptive cohort study utilized electronic health record data collected between January 1, 2021, and August 1, 2025. Adult patients admitted to inpatient services who received an order for linezolid within 16 days of serotonergic agent administration were included; pregnant patients were excluded. Serotonin syndrome was identified by documented ICD-10 diagnosis and/or cyproheptadine administration. Data was analyzed using descriptive statistics, including measures of central tendency, dispersion, and percentages.

Results: Primary outcomes showed 69% of linezolid–serotonergic agent (SA) co-administrations had no provider or pharmacist interventions. Providers most often held/switched/dose-reduced SAs (49%), followed by holding/switching linezolid (31%) or no change (20%). Pharmacists recommended SA modifications in 78% of cases, no change with documented low serotonin syndrome (SS) risk in 17%, and linezolid changes in 5%. Patients were on 1–5 SAs; most interventions occurred with 1 (61%) or 2 (31%) SAs. Apart from one case, pharmacist interventions increased with SA count. No SS cases or cyproheptadine use were observed.

Conclusions: Pharmacists and providers often held or modified SAs despite the low incidence of serotonin syndrome (SS) reported in the literature. Avoiding SS through prescribing changes may lead to unintended consequences, including suboptimal infection management, withdrawal or worsening of comorbid conditions, and prolonged interruption of SAs. These findings support considering continuation of linezolid with SAs. No patients in this cohort experienced SS, consistent with published evidence.

Self-assessment Question: True or False: Linezolid should be avoided at all costs in patients taking SAs due to a high risk of SS.

Title: Evaluation of heparin dosing in obesity for treatment of deep vein thrombosis and pulmonary embolism. 

Authors: Elise Paskowski, PharmD; Brandon Snyder, PharmD, BCPS 
Acknowledgments: Aundrea Rosenberger, PharmD, BCIDP; Theodore Bell, MS 

Objective: This study aims to look at the safety of using actual body weight in our deep vein thrombosis (DVT) and pulmonary embolism (PE) heparin protocol by comparing supratherapeutic aPTT values in obese and non-obese populations. 

Background: Obesity rates in the United States are rising, yet venous thromboembolism (VTE) guidelines lack dosing strategies for obese patients. Research has shown mixed results, supporting the use of actual bodyweight or adjusted bodyweight in obese patients. 

Methods: A retrospective chart review was conducted from May 1, 2024, to September 1, 2025, on patients who were ordered the heparin DVT/PE order set. Inclusion criteria were age ≥18, one aPTT drawn 5–7 hours after heparin initiation, and dosing based on actual body weight with no prespecified cap. Exclusion criteria included pregnancy, prior heparin use, no bolus given, protocol ordered but not administered, non-protocol aPTT goals, incorrect timing, or use of non-actual body weight. Currently at WellSpan Ephrata Community Hospital, patients receive an 80 unit/kg bolus dose followed by 18 unit/kg/hr based on actual body weight. Average aPTT values were compared between obese (BMI ≥ 30kg/m2) and non-obese patients. The primary outcome is a comparison of the average first aPTT values in the obese vs non-obese populations. The secondary outcome is the incidence of major bleeding events. 

Results: Mean aPTT values were compared between obese and non-obese populations. For the primary outcome, the mean aPTT in the non-obese group was 79.4 seconds. The mean aPTT in the obese group was 105.19 seconds. The institutional therapeutic range for aPTT values is 45-70 seconds. Major bleeding events occurred in eight patients from the non-obese group and one patient from the obese group. Major bleeding events were defined as bleeding that led to a drop in hemoglobin of greater than or equal to 2, a drop in hemoglobin requiring a transfusion or a bleed in a critical site like the cerebrum or abdominal area. A demographic comparison was completed between groups. 

Conclusions: Supratherapeutic aPTT values are a nursing-driven protocol. Using adjusted body weight in obese patients reduces mean aPTT and nursing workload. Elevated aPTT values put both populations at risk for major bleeds. These findings support using adjusted body weight in obese patients. Limitations to this study include being a single-center retrospective chart review with a small sample size, evaluating one indication at a single time point. 

Self-assessment question: 
What are some benefits to using adjusted bodyweight in obese patients shown by this study? (Choose all that apply) 
A. Decreased bleeding events
B. Decreased nurse workload
C. Decreased mean aPTT value
D. Increased bleeding events   

References:  

1. Pennsylvania department of health. Obesity. Commonwealth of Pennsylvania. https://www.pa.gov/agencies/health/diseases-conditions/chronic-disease/obesity. 2025. Accessed on August 3, 2025.  
2. Gerlach AT, Folino J, Morris BN, Murphy CV, Stawicki SP, Cook CH. Comparison of heparin dosing based on actual body weight in non-obese, obese and morbidly obese critically ill patients. Int J Crit Illn Inj Sci. 2013;3(3):195-199. doi:10.4103/2229-5151.119200 
3. J. Hirsh, S. S. Anand, J. L. Halperin, & V. Fuster. Circulation. Guide to Anticoagulant Therapy: Heparin: A Statement for Healthcare Professionals From the American Heart Association. AHA/ASA Journals. https://www.ahajournals.org/doi/10.1161/01.cir.103.24.2994. June 19, 2001. Accessed August 3, 2025.  
4. Fan J, John B, Tesdal E. Evaluation of heparin dosing based on adjusted body weight in obese patients. Am J Health Syst Pharm. 2016;73(19):1512-1522. doi:10.2146/ajhp150388
5. M. Safani, S. E. Hill, R. Winters, S. Kawanishi, S. W. Eppstein, S. Min, & M. Drachenberg. CHEST journal. The Use of Average Body Weight in Dosing Unfractionated Heparin. https://journal.chestnet.org/article/S0012-3692(13)60435-3/fulltext#:~:text=recommend%20the%20use%20of%20weight,)%20of%200.07%20L/kg. June 2013. Accessed August 3, 2025.  
6. Nguyen K, Murray B, Campbell-Bright S, et al. Adjusted Versus Total Body Weight Dosing for Intravenous Heparin Infusions and Target Attainment in Obese Patients. Hosp Pharm. Published online June 29, 2025. doi:10.1177/00185787251348377 

Title: Impact of pharmacist-led interventions on zolpidem de-escalation in hospitalized geriatric patients

Authors: N Lukan, PharmD; M Spoor PharmD, BCPS; C Maness PharmD, BCPS; T Hazirjian, PharmD; J Spano, PharmD

Learning Objective: At the end of this presentation the audience should be able to describe strategies to optimize zolpidem usage in geriatric patients

Self-assessment question: Which of the following pharmacist-led interventions can help reduce inappropriate zolpidem prescribing in hospitalized geriatric patients? (select all that apply)
a. Performing automatic dose reduction of zolpidem from 10 mg to 5 mg
b. Discouraging the new initiation inpatient zolpidem
c. Educating prescribers, nursing staff, and pharmacists about the risks of zolpidem
d. Encouraging zolpidem to be administered on a scheduled basis as opposed to as needed

Background/Objective: The objective of this study is to evaluate the impact of pharmacist-led interventions on the number of zolpidem orders and mean dose of zolpidem in hospitalized geriatric patients.
 
Methods: This retrospective study assessed zolpidem prescribing patterns before and after targeted pharmacist-led interventions. The pre-intervention group included patients hospitalized from December 2024 to February 2025 and the post-intervention group included patients from January 2026 to March 2026. Patients with an inpatient order for zolpidem were eligible for inclusion if they were 65 years of age or above. Patients were excluded if an order for comfort measures was placed at any time during their hospitalization. The primary outcome measures were the number of orders for zolpidem per 1000 patient days and the mean dose of zolpidem ordered. Secondary outcome measures included 30-day all-cause readmission rates, number and type of pharmacist interventions, number of documented falls, and retention of intervention at discharge. Categorical variables were analyzed using Chi-square tests and continuous variables were assessed using paired student’s t-tests.

Results: A total of 172 zolpidem orders were reviewed with 131 meeting inclusion criteria. After four orders were excluded, the pre-intervention group contained 71 orders, and the post-intervention group contained 56 orders. Baseline characteristics were similar between groups. The primary outcomes were not statistically different between pre- and post-intervention groups. Among secondary outcomes, documented pharmacist interventions increased significantly post-intervention (p = 0.036), with dose change interventions representing the predominant increase in intervention type (p = 0.001). Post-hoc analysis demonstrated a statistically significant decrease in mean zolpidem dose administered in the post-intervention group (p = 0.017).  

Conclusion: Implementation of an automatic dose reduction protocol and targeted pharmacist-led interventions led to no change in number of zolpidem orders, no change in mean dose of zolpidem ordered, significant reduction in mean administered dose of zolpidem and increase in documented pharmacist interventions. Further study is warranted to evaluate strategies that sustain pharmacist interventions at discharge.

Title: Evaluation of smoking cessation therapy orders in hospitalized patients (STOP) - Phase 2
Authors: Hannah Seo, PharmD; Thom Coco, PharmD, BCPS, CTTS; Christopher Ullo, PharmD, CCRP; Joanna Stanton, PharmD, BCPS; Aneeqa Islam, PharmD, BCPS
Learning objective: Audience members will be able to describe the impact of a standardized nicotine replacement therapy (NRT) order panel on prescribing rates of NRT in the inpatient setting. 
Background/objective: Prescribing rates for NRT are low in our institution (28.5% in-hospital, 15.9% at discharge). After the implementation of an updated, guideline-directed NRT order panel in August 2025, this project aimed to determine if the new panel increased prescribing rates for patients.
Methods: This is an institutional review board approved chart review that assessed NRT prescribing rates in patients admitted to medical-surgical units who identified as active tobacco smokers at a large academic medical center from October 2025 to January 2026. Patients were excluded if they were non-cigarette smokers, expired during admission, received hospice care, admitted to intensive care, pediatric, or psychiatric units, were observation or same-day surgical patients, discharged to rehabilitation or nursing facilities, left against medical advice, or had incomplete documentation. The primary endpoint was the prescribing rates of NRT in patients who identified as active smokers. Secondary endpoints included percentage of patients counseled during index stay, percentage of NRT prescriptions provided at discharge, percentage of patients with a high risk or respiratory disease, number of monotherapy patch or gum orders, percentage of appropriate dose, and number of home NRT continued.
Results: There were a total of 374 out of 1,252 patients that were included and analyzed. The majority of the patients were male, white, and an average age of 58 years old. Most patients did not have high risk comorbidities, but of the ones that did, COPD was the most common. NRT was ordered for 89 patients (23.8%): 75 patch only, 4 gum only, and 10 both. Smoking cessation counseling was documented for 164 patients (43.9%), and NRT discharge prescriptions were written for 12% of patients.
Conclusion: Compared to the previous chart review before the order panel was established, we observed a decrease in inpatient NRT prescribing rates and discharge prescriptions, but there was an increase in counseling rates (36.3% v 43.85%). Further research could explore the impact of pharmacist-led NRT ordering and utilization of an interdisciplinary approach involving the substance use counselors to improve accurate documentation of smoking status and increase utilization of combination therapy.
Self assessment question: True or false: Current guidelines recommend behavioral counseling and combination nicotine replacement therapy to increase success rates of smoking cessation.
a. true
b. false

Title: Comparative Review of Phenobarbital Versus Lorazepam for the Treatment of Acute Alcohol Withdrawal

Investigators: Olivia Langlois, PharmD, Christopher Devine, PharmD, BCPS, BCCCP, Alexis Small, PharmD, BCPS, Jessica Marx, PharmD, BCPS

Learning Objective: By the conclusion of this presentation, participants will be able to compare the safety and efficacy of phenobarbital and lorazepam for the treatment of acute alcohol withdrawal.

Objective: This study aims to evaluate safety and efficacy outcomes of lorazepam guided by the CIWA-Ar protocol versus phenobarbital per hospital-specific pharmacy dosing protocol in the management of inpatient acute alcohol withdrawal.

Methods: This retrospective study reviewed patients admitted with a diagnosis of acute alcohol withdrawal. Patients included all hospitalized adults greater than 18 years old treated for acute alcohol withdrawal with either lorazepam per CIWA-Ar protocol or phenobarbital per pharmacy dosing protocol from April 1, 2025 to July 31, 2025 at a 240-bed academic teaching hospital in Portsmouth, New Hampshire. Patients transferred from outside facilities already receiving either medication were excluded. Data was extracted from the hospital’s electronic health record system. All data was de-identified and securely stored for analysis. Primary outcomes include the length of hospital stay and need for transfer to the intensive care unit. Secondary outcomes assessed the incidence of seizures and acute hypoxic respiratory failure from overmedication leading to intubation. This research was deemed exempt from Institutional Review Board (IRB) oversight in accordance with institutional policy.

Results: A total of 202 patients met inclusion criteria; 73 received lorazepam and 129 received phenobarbital. The baseline characteristics were similar between the two groups. The mean length of hospital stay in the lorazepam and phenobarbital groups was 6.16 days and 7.77 days, respectively (p = 0.236). Eleven (8.5%) patients receiving phenobarbital were transferred to the intensive care unit due to alcohol withdrawal versus 4 patients (5.5%) receiving lorazepam (p = 0.214). Five (3.9%) patients receiving phenobarbital had a reported seizure versus 2 (2.7%) patients receiving lorazepam (p = 0.336). The incidence of acute hypoxic respiratory failure was low, with 3 (2.3%) in the phenobarbital group and 3 (4.1%) in the lorazepam group (p = 0.237). 

Conclusion: There was no statistical difference between phenobarbital and lorazepam for the treatment of acute alcohol withdrawal for the outcomes above. Patients in the phenobarbital group, however, had a higher incidence of withdrawal seizures and delirium tremens at baseline, putting them at higher risk of adverse outcomes. About half the patients in the phenobarbital group with an adverse outcome received a suboptimal loading dose; and only a small percentage of patients completed the taper.

Self-Assessment Question: Which of the following is true based upon the results of the study “Comparative Review of Phenobarbital Versus Lorazepam for the Treatment of Acute Alcohol Withdrawal”?

1. Phenobarbital is associated with fewer alcohol withdrawal-related seizures than lorazepam
2. Patients who received phenobarbital are at an increased risk of developing acute hypoxic respiratory failure compared to lorazepam
3. For patients seeking alcohol withdrawal treatment in the inpatient setting, lorazepam was associated with a longer average length of hospital stay versus phenobarbital
4. Further research is needed to determine a standardized loading dose and duration of therapy for phenobarbital to treat acute alcohol withdrawal

Disclaimer: This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare affiliated entity. The views expressed in this publication represent those of the authors and do not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.

Authors: Han Jeong, PharmD; Julie M. Waldfogel, PharmD, BCGP, BCPMP; Suzanne Nesbit, PharmD, BCPMP, FCCP, FASHP; Tiffany Michalowski, PharmD, BCGP, BCPMP; Lisa Hutchins, PharmD, BCPPS

Learning Objective: Describe the structured implementation andassessment of a PCA competency plan forpharmacists who verify orders

Opioids are high-risk medications. This project develops and implements a PCA competency to improve analgesic safety, enhance pharmacist workflow, and support better patient outcomes through more consistent PCA practices across the institution. 

A formal competency module was established to encompass case-based scenarios, knowledge assessments, and workflow simulations tailored to institutional practices. Educational materials covering PCA principles, dose verification, and population-specific considerations for adult and pediatric populations were developed and integrated into a shared pharmacy education platform. To ensure organizational alignment, the implementation strategy was developed by involving key administrative and clinical stakeholders. Targeted pharmacist audiences were identified to ensure comprehensive clinical proficiency. All assessment materials underwent review by a specialized clinician group to ensure clinical standardization and  accuracy. Implementation followed a structured plan including departmental communication and competency facilitation supported by a sustainability plan to ensure long-term operational longevity. 

Deliverables including educational content slides and a comprehensive competency development plan have been finalized, incorporating feedback from key stakeholders and other competency module stewards. Educational materials and assessments have been reviewed by clinical experts. Next steps include submitting the final plan for leadership approval, assessment upload onto the shared education platform, and module roll out.  Final results will report on departmental integration to assess the module's effectiveness in ensuring clinical proficiency. 

The implementation of this competency module is expected to enhance pharmacist workflow efficiency and reduce variability in PCA practices. By aligning with national safety standards and providing targeted adult and pediatric training, the project will support better patient outcomes through safer analgesic management. Processes will be established for ongoing updates to ensure the continuous improvement and sustainability of the competency.  

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.