Publications by authors named "Melissa J Snider"

10 Publications

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Trends in anticoagulation management services following incorporation of direct oral anticoagulants at a large academic medical center.

J Thromb Thrombolysis 2021 May 9;51(4):1050-1058. Epub 2020 Oct 9.

The Ohio State University Wexner Medical Center, Columbus, OH, 43228, USA.

The introduction of direct oral anticoagulants (DOACs) to the market has expanded anticoagulation options for outpatient use. Routine evaluation by health care professionals is recommended as it is with warfarin, therefore requiring adjustments in practices of anticoagulation management services (AMS). This study aims to describe trends that occurred following the incorporation of DOACs into AMS at a large academic medical center. A retrospective chart review of pharmacist-run AMS was used to compare patients on DOAC therapy versus other types of anticoagulation, including warfarin and parenteral agents. Primary outcomes included trends in the number of unique patients, management encounters, and telephone encounters throughout the study period. Secondary outcomes included trends in new encounters, and changes in patient characteristics, resources utilized, and patient satisfaction scores. A total of 2976 unique patients, 74,582 management encounters, and 13,282 telephone encounters were identified. From study beginning to end, results showed stable numbers of unique patients, an increase in management encounters for the DOAC group and decrease in the other anticoagulants group, and stable numbers of telephone encounters. Additionally, the number of new encounters for both groups increased. Throughout the study, pharmacy resources were reallocated within anticoagulation to adapt to the changing trends and patient satisfaction reached targets. Patients' characteristics remained stable, with the DOAC group having fewer comorbid conditions and concomitant medications that could increase bleed risk. This study showed that by reallocating resources within anticoagulation, AMS can maintain stable patient populations while continuing to expand access and satisfy patients following DOAC inclusion.
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http://dx.doi.org/10.1007/s11239-020-02286-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7546384PMC
May 2021

Risk Versus Benefit of Combined Aspirin and Warfarin Therapy in Patients With Atrial Fibrillation.

J Pharm Pract 2020 Apr 15:897190020916638. Epub 2020 Apr 15.

Ohio State University Wexner Medical Center, Columbus, OH, USA.

Purpose: Guidelines have differing recommendations for aspirin use in patients with an indication for anticoagulation. The purpose of this study was to evaluate the incidence of major bleeding and thromboembolic events (TEs) in patients with atrial fibrillation (AF) receiving warfarin alone (monotherapy group) versus warfarin plus aspirin (combination therapy group).

Methods: This was a retrospective, cohort study including patients from a pharmacist-run anticoagulation clinic. Inclusion criteria were patients with AF receiving anticoagulation between January 2013 and January 2014 observed over 5 years.

Results: One hundred forty-two patients were included in the combination group versus 89 in monotherapy group. In the combination group, 60 (42.3%) patients were on aspirin for no apparent indication, 19 (13.4%) had stable coronary artery disease and diabetes, and 26 (18.3%) had diabetes alone. Major bleeding occurred in 21 (14.9%) patients in the combination group versus 7 (7.9%) patients in the monotherapy group (odds ratio [OR] = 2.02, 95% confidence interval [CI]: 0.78-5.91; = .17). TE occurred in 10 (7%) patients in the combination group versus 4 (4.5%) in the monotherapy group (OR = 1.61, 95% CI: 0.44-7.24; = .57). There was no significant difference in bleeding ( = .85) or TE ( = .37) rates between aspirin indications in the combination group.

Conclusion: Combination therapy versus monotherapy may increase bleeding risk with little benefit in decreasing AF-related stroke or cardiovascular events.
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http://dx.doi.org/10.1177/0897190020916638DOI Listing
April 2020

Improvement in the medication reconciliation postdischarge quality measure after implementation of a pharmacist-run service.

J Am Pharm Assoc (2003) 2020 Mar - Apr;60(2):391-396. Epub 2019 Dec 6.

Objective: This study aimed to evaluate the impact of a pharmacist-led postsurgical discharge medication reconciliation program in an accountable care organization-like setting.

Setting: Multidisciplinary primary care network in Central Ohio.

Practice Description: Ambulatory care pharmacists are integrated in a primary care network, which includes a centralized focus on assistance with population health metrics, along with an interdisciplinary team.

Practice Innovation: In May 2018, a pharmacist-led medication reconciliation postdischarge (MRP) program was initiated focused on a postsurgical discharge population.

Evaluation: A retrospective chart review was conducted to compare the 2 primary end points of overall MRP rates from 4 payers in 2017 and 2018, and the postsurgical MRP rates from May 25 to November 30 of 2017 and 2018. Secondary outcomes included description of pharmacist interventions in pharmacy-led service and 30-day readmission or emergency department (ED) utilization rates for postsurgical population.

Results: A total of 5837 hospitalizations were identified as eligible for overall MRP completion in 2017 (n = 2621) and 2018 (n = 3216). A 20% relative increase in overall MRP completion was reported in 2018 (P < 0.001). In 2017, 55.9% of postsurgical MRPs were completed. The implementation of the pharmacy-led MRP program led to a 41% relative increase in postsurgical MRP completion (78.9% in 2018, P < 0.001). Pharmacists completed 220 postsurgical MRPs in the 6-month study period, including 765 total recommendations for intervention and an average of 3 recommendations and 4 medication list updates per MRP. There was no statistically significant reduction in 30-day readmission and ED utilization rates in 2018 (6.8% in 2017 vs. 6.2% in 2018, P = 0.74).

Conclusion: A pharmacy-led postsurgical discharge program led to an increase in MRP completion rates in the target postsurgical MRP population, which also positively affected the overall MRP completion rate. Pharmacists can be key players in the improvement and quality of MRP measures.
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http://dx.doi.org/10.1016/j.japh.2019.10.006DOI Listing
June 2021

Safety of Twice Daily Sotalol in Patients with Renal Impairment: A Single Center, Retrospective Review.

J Atr Fibrillation 2018 Oct-Nov;11(3):2047. Epub 2018 Oct 31.

The Ohio State University Wexner Medical Center 452 West 10th Ave Columbus, OH 43210.

Background: The class III antiarrhythmic sotalol is renally eliminated with a dose-related propensity to cause adverse drug reactions (ADR) potentially leading to life-threatening arrhythmias. Although product labeling recommends once daily dosing in patients with renal impairment, twice daily dosing is commonly utilized. This study evaluates the safety of this practice.

Methods: This retrospective, observational study examined renally impaired patients with atrial fibrillation or atrial flutter admitted for sotalol initiation from July 1, 2012 - December 31, 2014, then for up to 20 months after initiation. Primary endpoints included rates of ADR and therapy changes due to ADR. Secondary endpoints included therapy changes due to arrhythmia recurrence, admissions due to arrhythmia recurrence, and therapy changes for any cause.

Results: Analysis included 134 patients with an average creatinine clearance of 51 ml/min, followed over a median of 170 days. Length of stay averaged 3 days withADR occurring in 53.7% of patients, most commonly QT prolongation or bradycardia. Therapy change due to ADR occurred in 45.5% of patients (n=61). Therapy change due to arrhythmia recurrence occurred in 23.1% (n=31), admission due to arrhythmia recurrence occurred in 24.6% (n=33), and therapy change for any cause occurred in 74.6% (n=100).

Conclusion: Initiating sotalol twice daily in renally impaired patients results in ADR and therapy change rates consistent with rates seen in clinical practice for non-renally impaired patients, with minimal length of stay.This practice may be reasonable when initiated in the acute care setting with subsequent outpatient monitoring, however further study is needed.
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http://dx.doi.org/10.4022/jafib.2047DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6533816PMC
October 2018

Tolerance of Proprotein Convertase Subtilisin/Kexin type 9 (PCSK9) Inhibitors in Patients With Self-Reported Statin Intolerance.

J Pharm Pract 2020 Jun 16;33(3):276-282. Epub 2018 Sep 16.

The Ohio State University Wexner Medical Center, Columbus, OH, USA.

Background: Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors have been shown to lower atherogenic lipid markers in patients with statin intolerance; however, external validity of these findings is unclear in patients with self-reported statin intolerance.

Objective: The objective of this study was to describe the tolerability of evolocumab and alirocumab in patients with self-reported statin intolerance. Secondary objectives were to describe their efficacy and obtainability.

Methods: A retrospective chart review was completed and included adult patients with self-reported statin intolerance who were prescribed a PCSK9 inhibitor. Patient-reported side effects, laboratory values, and insurance information were collected for assessment of study objectives.

Results: During the study period, 55 patients were prescribed PCSK9 inhibitor, 42 started therapy, and 34 had at least 1 follow-up visit. While myalgias occurred in 14.7% (n = 5) of patients, flu-like symptoms in 11.8% (n = 4), and fatigue in 2.9% (n = 1), only 5.9% (n = 2) of prescriptions for PCSK9 inhibitors were discontinued. Low-density lipoprotein cholesterol (LDL-C) was reduced 48.7% (95% confidence interval [CI]: -1.7%-99.1%), and 20 (58.8%) patients achieved a ≥50% reduction in LDL-C. Regarding obtainability, of the 57 prescriptions written, 77.2% (n = 44) required prior authorization and 5.3% (n = 3) were denied by insurance.

Conclusion: PCSK9 inhibitors were well tolerated in patients with self-reported statin intolerance.
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http://dx.doi.org/10.1177/0897190018799218DOI Listing
June 2020

Impact of clinical pharmacists on atherosclerotic risk factor management in an integrated heart and vascular clinic.

Vasc Med 2018 02 17;23(1):80-81. Epub 2018 Jan 17.

2 The Ohio State University Wexner Medical Center CarePoint East, Columbus, OH 43203, USA.

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http://dx.doi.org/10.1177/1358863X17747722DOI Listing
February 2018

Initiation and outcomes with Class Ic antiarrhythmic drug therapy.

Indian Pacing Electrophysiol J 2018 Mar - Apr;18(2):68-72. Epub 2017 Dec 7.

Ohio State University Wexner Medical Center, Division of Cardiovascular Medicine, USA. Electronic address:

Background: Expert opinion recommends performing exercise testing with initiation of Class Ic antiarrhythmic medication.

Objective: To evaluate the rate and reason for discontinuation of Ic agent within the first year of follow up, with particular attention to rate of proarrhythmia and the value of routine treadmill testing.

Methods: This is a single center retrospective cohort study including consecutive patients with atrial arrhythmias who were initiated on a Class Ic agent from 2011 to 2016. Data was collated from chart review and pharmacy database.

Results: The study population included 300 patients (55% male, mean age 61; mean ejection fraction, 56%) started on flecainide (n = 153; 51%) and propafenone (n = 147; 49%). Drug initiation was completed while hospitalized on telemetry and the staff electrophysiologists directed dosing. There was one proarrhythmic event during initiation (0.3%). The primary reason for not being discharged on Ic agent was due to detection of proarrhythmia (n = 15) or ischemia (n = 1) with treadmill testing (5.3%). Exercise testing was the single significant variable to affect the decision to discontinue Ic drug, p < 0.0001 (95% CI: 1.89-6.08%). During follow up, the primary reason for discontinuation of Ic agent was lack of efficacy, 32%.

Conclusions: With proper screening, initiation of Class Ic agent is associated with very low rate of proarrhythmia. Treadmill testing is of incremental value and should be completed in all patients after loading Class Ic antiarrhythmic.
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http://dx.doi.org/10.1016/j.ipej.2017.12.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5998214PMC
December 2017

Evaluation of a pharmacist-managed electrolyte protocol in outpatients on antiarrhythmic medications.

J Am Pharm Assoc (2003) 2017 Jul - Aug;57(4):526-531. Epub 2017 Jun 10.

Objective: To evaluate the effectiveness of a pharmacist-managed treatment protocol in achieving and maintaining serum potassium level ([K]) in the desired range.

Setting: Antiarrhythmic Medications Clinic, The Ohio State University Wexner Medical Center, Columbus, Ohio, from 2009 to 2013.

Practice Description: Patients are referred for antiarrhythmic monitoring at this pharmacist-run, electrophysiologist-supervised clinic. Each visit includes medication reconciliation for drug interaction identification, patient interview for potential adverse effects or arrhythmia symptoms, patient education, and drug therapy monitoring through ordering and review of objective testing.

Practice Innovation: In 2009, a novel, pharmacist-managed electrolyte protocol was established for less than ideal [K] found during antiarrhythmic monitoring. The protocol was intended to standardize and improve practice, versus pre-protocol management through separate electrophysiology offices. The protocol was designed to maintain [K] of 4.0-5.0 mmol/L, and it used dietary advice and magnesium and potassium supplementation to normalize [K].

Evaluation: The performance of the pharmacist-managed electrolyte protocol was evaluated in consecutive patients seen between June 2009 and July 2013 with [K] less than 4.0 mmol/L. [K] during initial visit and laboratory tests were scheduled at weekly intervals after intervention until corrected. Maintenance of [K] was assessed during the next visit to the clinic. Patients whose management involved pre-protocol between October 2008 and May 2009 at the clinic served as controls.

Results: One-hundred ninety-one encounters were evaluated from the post-protocol (treatment) group and 41 encounters from the pre-protocol (control) group. Desired [K] was reached in 161 (84%) post-protocol patient encounters, compared with 21 (49%) in the control group (P < 0.01). Median time to target was 14 days (range, 3-203 days) in the treatment group and 146 days (range, 7-285 days) in the control group (P < 0.01). Of 125 encounters that received follow-up in the treatment group, 75% remained at desired [K].

Conclusion: A pharmacist-managed electrolyte protocol, implemented as part of a comprehensive antiarrhythmic monitoring service, effectively achieves and maintains desired [K].
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http://dx.doi.org/10.1016/j.japh.2017.05.001DOI Listing
February 2018

Statin desensitization in a patient with probable familial hypercholesterolemia.

J Clin Lipidol 2015 Jul-Aug;9(4):597-601. Epub 2015 Mar 19.

The Ohio State University Wexner Medical Center, Columbus, OH, USA.

Problem Overview: With cardiovascular disease being the leading cause of morbidity and mortality in the United States, cholesterol-lowering medications have become a prominent focus of medical management and cardiovascular risk reduction, including the use of statins making them the most widely prescribed class of medications in the United States and are the cornerstone of management of hyperlipidemia. This case report describes a 29-year-old female with probable familial hypercholesterolemia (FH) who had allergic reactions to statin therapy on two separate occasions. She required statin therapy based on her elevated carotid intima media thickness test, historic LDL-C ≥ 190 mg/dL, elevated Lp(a), and family history significant for premature coronary heart disease. In this report, we document a case of successful oral desensitization to rosuvastatin and propose a replicable statin desensitization protocol.

Major Management: The patient was admitted for rosuvastatin desensitization following predetermined protocols, utilizing an interdisciplinary team, and monitored for 24 hours following completion of administration prior to discharge. She successfully completed desensitization to rosuvastatin 10mg by mouth daily without anaphylactic reaction. She continued to tolerate rosuvastatin 10mg daily through most recent follow-up, and with this addition, significant improvement in lipid levels was achieved.

Conclusion: This case report presented a patient with probable FH who was previously intolerant to other statin therapies that underwent successful desensitization to rosuvastatin with subsequent achievement of therapy goals.
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http://dx.doi.org/10.1016/j.jacl.2015.03.004DOI Listing
May 2016
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