Label warnings, antibiotic measurements, cancer therapies, and smoking interventions take top honors at annual seminar

Studies of improved over-the-counter acetaminophen warning labels, more accurate measurements of antibiotics in hospitalized patients, therapies for metastatic breast cancer, and methods for training pharmacy personnel to help smokers quit took top honors at the Department of Clinical Pharmacy’s 16th Annual Spring Research Seminar.

The poster session, covering a total of 31 projects and highlighting research by UCSF School of Pharmacy student pharmacists, residents, and faculty members, was held on May 6, 2014, on the Parnassus campus.

Rifkind Award Winners

Winners of the 7th Annual Gary Rifkind Spring Research Seminar Awards are:

Student Pharmacist

Tien Ho, PharmD (class of 2014), for “Improved label and liver warning for nonprescription acetaminophen products.”

Resident

Alicia Harvey, PharmD, for “A multi-disciplinary approach to improving vancomycin trough level acquisition and interpretation using a computerized physician order entry system.”

Resident

Bao Dao, PharmD, MBA, for “Clinical efficacy of pertuzumab, trastuzumab, taxane therapy for metastatic breast cancer after first progression.”

Other

Robin Corelli, PharmD; Lisa Kroon, PharmD; Parisa Vatanka, PharmD; Kevin Rodondi, PharmD; Brian Hille, RPh; Karen Hudmon, DrPH, MS, RPh, for “Documentation of smoking status: Results from a randomized trial to promote brief smoking cessation interventions in community pharmacies.”

The Rifkind awards, $1,000 each, were created to recognize and inspire clinical pharmacy research. They are the gift of Gary Rifkind, PharmD, a UCSF School of Pharmacy alumnus, class of 1960. This year the monetary awards were given in the student pharmacist and resident categories, while the “other” category will receive a Rifkind certificate.

Comparing responses to label warnings

The poster lead-authored by Ho examined whether revised product labels and warnings for non-prescription acetaminophen products were more helpful than the current ones in helping consumers respond to an overdose scenario as well as in encouraging them to read and understand the label.

While widely available and commonly used for self-care of aches and pains, acetaminophen carries a relatively high risk of overdose, given the narrow difference between a safe and effective dose (up to 3,000 milligrams in 24 hours) and a dose that can cause severe liver damage (more than 4,000 mg in a day). Indeed, acetaminophen-related overdose is the top cause of acute liver failure and a leading cause of U.S. liver transplants.

Ho and co-authors, including William Soller, PhD, a faculty member in the School’s Department of Clinical Pharmacy, compared consumer response to the current Drug Facts labeling of over-the-counter acetaminophen-containing products versus revised labeling that they developed after reviewing scientific literature, consulting with liver transplant and poison control pharmacists, and running focus groups.

The researchers recruited 110 local study participants, who each read a scenario describing an inadvertent overdose. Participants were randomly divided into two groups. Half initially viewed only the current label and half initially viewed only the revised label. The groups were each asked how to respond to the described overdose. Then, in comparing the current and revised labels side-by-side, all were asked:

• How easy it was to find and understand the liver warning.
• Their overall preferences and views of the two labels’ usefulness.
• Whether bottle cap wording urging consumers to read the label plus the current “Contains acetaminophen” or the revised “Overdose may cause liver damage” increased their likelihood of label reading.

The results: 91 percent of those reading the revised labeling described correct overdose actions versus 76 percent viewing the current label. In addition, the study’s consumer sample preferred overall the researchers’ label revision, relocation, and reorganization of overdose and liver damage information as providing better prevention directions and more information.

The study's authors will present their findings at the upcoming annual conference of the Drug Information Association, and they plan to publish the study in a peer-reviewed journal as well.

Improving antibiotic measurements

The study by Harvey and colleagues examined whether the accurate measurement of antibiotic blood levels in hospitalized patients could be improved via changes in workflow and the computerized systems used by clinicians to order and track drug dosing and blood draws.

The effectiveness of vancomycin, which is given to treat and prevent serious infections, depends on maintaining a certain concentration range of the drug in blood plasma over time. It has been found that the best way to determine if a patient has enough of this antibiotic circulating to be effective—as well as to monitor for toxic build-up—is to take a blood sample (or draw) at the trough level (the presumed low point of drug concentration before the next scheduled dose) just before the fourth dose is administered.

However, a previous evaluation of such vancomycin-monitoring blood draws at UCSF Medical Center found that they were done with that ideal timing only 13 percent of the time. As described in their poster, Harvey et al. conducted a multidisciplinary quality improvement pilot project on two adult acute-care floors at UCSF Medical Center over the course of several weeks.

Among the project’s workflow changes:

• Physicians, when entering orders for vancomycin-monitoring blood draws in the hospital’s computerized system, were to indicate that they were “timed” draws—not “routine” draws—and note that they were to be done “before the 4th dose.”
• Nurses were to document the expected timing of that pre-4th-dose blood draw, and then verify it before giving each new vancomycin dose.
• Pharmacists were to proactively reset incorrectly timed blood draw orders, order trough blood draws as needed, and conduct health care team education.

The results: The accuracy of vancomycin trough level blood sampling, among 45 such orders, increased to 91 percent. There are now plans to expand the pilot project hospital-wide, to be followed by an analysis of cost savings and patient outcomes.

Analyzing therapies for metastatic breast cancer

The study by Dao and colleagues analyzed whether using a combination of chemotherapy drugs shown to reduce the progression of metastatic breast cancer (MBC) and increase how long MBC patients lived when used as a first-line treatment—that is, when used against previously untreated metastatic breast cancer—would also improve the progression-free survival of patients with MBC who had previously received chemotherapy.

The particular regimen adds the drug pertuzumab (a laboratory-generated antibody that binds to and inhibits HER2, a protein that promotes cell proliferation), to another HER2 inhibitor and a chemotherapy agent. HER2 is increased in quantity (overexpressed) in about 20 percent of breast cancers and is associated with higher rates of cancer cell proliferation and a more negative prognosis.

Dao et al. retrospectively analyzed the treatment results for two groups of patients with metastatic breast cancer who had tested positive for HER2 overexpression and who were treated at UCSF’s Helen Diller Comprehensive Cancer Center between July 2011 and November 2013:

• One group of 20 patients received the current standard of care: treatment with trastuzumab (another HER2 antibody type of drug) along with one other approved chemotherapy or hormone therapy.
• A second group of 19 patients received trastuzumab plus pertuzumab as well as a taxane-class chemotherapy drug.

The result: For these groups of metastatic breast cancer patients, the additional use of pertuzumab did not result in longer progression-free survival rates over the two-and-a-half year period examined in the study. Dao and colleagues plan to present and discuss their results with breast oncologists.

Evaluating smoking intervention training

The study by Corelli and colleagues examined two methods for training community pharmacy personnel to identify and help smokers who want to quit. Dubbed Ask-Advise-Refer, the intervention entails asking patients if they smoke, advising them to quit, and referring those ready to stop smoking to a tobacco quitline that provides comprehensive help.

The study arises from a partnership established between the School and the Safeway supermarket chain’s pharmacy department. In a pilot version of a program expected to be rolled out nationally, School faculty trained Safeway pharmacists at 20 California locations in the Ask-Advise-Refer model.

Corelli et al. compared the effects of training pharmacy personnel in the pilot via written materials only or supplementing those materials with four hours of live training, plus active monitoring and coaching by Safeway pharmacy management. Pharmacy sites were randomized and the study tracked the activities of 42 pharmacists and 46 technicians/clerks before training, post-training, and at 6 and 12 weeks after initial training.

The study found significant differences in rates of pharmacy personnel asking patients about tobacco use and documenting their smoking status when they were given the supplemental live training, monitoring, and coaching in addition to written materials:

• Initially, 84 percent of pharmacists and 96 percent of technicians/clerks had not asked any patients about their smoking status in the past week. After three months, about 85 percent of pharmacists trained with either approach had asked; but among technicians/clerks, 75 percent receiving training via written materials only had asked, versus 91 percent of those who had live training plus coaching/monitoring.
• Documentation of patients’ smoking status in pharmacy computer profiles also increased. After 12 weeks, among those trained with written materials alone, the weekly cumulative percentage of such documentation was 27 percent versus 45 percent for those with the added live training plus monitoring/coaching. Beyond cessation interventions, such documentation allows screening for possible drug interactions with tobacco smoke.