Evaluation of a computer‐based intervention to enhance metabolic monitoring in psychiatry inpatients treated with second‐generation antipsychotics

What is known and Objective: Second‐generation antipsychotics (SGAs) play an important role in the pharmacologic management of various psychiatric conditions. Use of these medications has been associated with metabolic complications. Adherence to guideline‐recommended monitoring is suboptimal. We evaluated the effect of a computerized physician order entry (CPOE) pop‐up alert designed to improve rates of laboratory metabolic monitoring of patients treated with SGAs on a University Hospital inpatient psychiatry unit. Methods: A single‐centre, retrospective chart review was performed in which patient demographics and SGA drug and laboratory data were extracted from the CPOE database. We assessed the number of orders for appropriate metabolic monitoring data for patients admitted within a 6‐month period before or after the alert implementation. Results and Discussion: Pre‐alert (n = 171) and post‐alert (n = 157) groups were similar with respect to age, length of stay, sex, race and comorbidities. Following alert implementation, significant increases in monitoring both random (92·4% vs. 100%) and fasting (46·8% vs. 70%) glucose levels as well as random (28·7% vs. 74·5%) and fasting (18·7% vs. 59·9%) lipid panels (all P ≤ 0·001) were observed. The number of patients with both a fasting glucose level and fasting lipid panel available for monitoring increased from 12·9% to 47·8% (P < 0·0001). Significantly more post‐alert laboratory orders were submitted at the same time as the SGA drug order (P < 0·0001), suggesting that the alert itself had a direct influence on the ordering of metabolic monitoring labs. What is new and Conclusions: Implementation and use of an electronic pop‐up alert in an inpatient psychiatric unit significantly improved rates of ordering fasting blood glucose and lipid levels for inpatients treated with SGAs. Overall rates remain suboptimal, suggesting a need for additional strategies to further improve metabolic monitoring.     

Transitional NPH Insulin Therapy for Critically Ill Patients Receiving Continuous Enteral Nutrition and Intravenous Regular Human Insulin

Background: The intent of this study was to evaluate the efficacy and safety of transitioning from a continuous intravenous (IV) regular human insulin (RHI) or intermittent IV RHI therapy to subcutaneous neutral protamine Hagedorn (NPH) insulin with intermittent corrective IV RHI for critically ill patients receiving continuous enteral nutrition (EN). Methods: Data were obtained from critically ill trauma patients receiving continuous EN during transitional NPH insulin therapy. Target blood glucose concentration (BG) range was 70–149 mg/dL. BG was determined every 1–4 hours. Results: Thirty‐two patients were transitioned from a continuous IV RHI infusion (CIT) to NPH with intermittent corrective IV RHI therapy. Thirty‐four patients had NPH added to their preexisting supplemental intermittent IV RHI therapy (SIT). BG concentrations were maintained in the target range for 18 ± 3 and 15 ± 4 h/d for the CIT and SIT groups, respectively (P < .05). Thirty‐eight percent of patients experienced a BG <60 mg/dL, and 9% had a BG <40 mg/dL. Hypoglycemia was more prevalent for those who were older (P < .01) or exhibited greater daily BG variability (P < .01) or worse HgbA_1C (p < 0.05). Conclusion: Transitional NPH therapy with intermittent corrective IV RHI was effective for achieving BG concentrations within 70–149 mg/dL for the majority of the day. NPH therapy should be implemented with caution for those who are older, have erratic daily BG control, or have poor preadmission glycemic control.     

Drug‐Nutrient Interactions

Drug‐nutrient interactions are defined as physical, chemical, physiologic, or pathophysiologic relationships between a drug and a nutrient. The causes of most clinically significant drug‐nutrient interactions are usually multifactorial. Failure to identify and properly manage drug‐nutrient interactions can lead to very serious consequences and have a negative impact on patient outcomes. Nevertheless, with thorough review and assessment of the patient's history and treatment regimens and a carefully executed management strategy, adverse events associated with drug‐nutrient interactions can be prevented. Based on the physiologic sequence of events after a drug or a nutrient has entered the body and the mechanism of interactions, drug‐nutrient interactions can be categorized into 4 main types. Each type of interaction can be managed using similar strategies. The existing data that guide the clinical management of most drug‐nutrient interactions are mostly anecdotal experience, uncontrolled observations, and opinions, whereas the science in understanding the mechanism of drug‐nutrient interactions remains limited. The challenge for researchers and clinicians is to increase both basic and higher level clinical research in this field to bridge the gap between the science and practice. The research should aim to establish a better understanding of the function, regulation, and substrate specificity of the nutrient‐related enzymes and transport proteins present in the gastrointestinal tract, as well as assess how the incidence and management of drug‐nutrient interactions can be affected by sex, ethnicity, environmental factors, and genetic polymorphisms. This knowledge can help us develop a true personalized medicine approach in the prevention and management of drug‐nutrient interactions.