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Pharmacist-Led Education for Increasing Physician Comfort Prescribing Oral COVID-19 Antivirals

Published:September 25, 2022DOI:https://doi.org/10.1016/j.amjmed.2022.09.010
      Two novel oral antiviral therapeutics, molnupiravir (Lagevrio; Merck) and ritonavir-boosted nirmatrelvir (Paxlovid; Pfizer Inc) (nirmatrelvir-ritonavir), were recently approved by the US Food and Drug Administration under an Emergency Use Authorization for the treatment of patients with mild to moderate coronavirus disease 2019 (COVID-19) at high risk of progression to severe disease.

      Food and Drug Administration. Fact sheet for healthcare providers: emergency use authorization for Paxlovid. Available at: https://www.fda.gov/media/155050/download. Accessed May 25, 2022.

      ,

      Food and Drug Administration. Fact sheet for healthcare providers: emergency use authorization for Lagevrio (molnupiravir) capsules. Available at: https://www.fda.gov/media/155054/download. Accessed May 26, 2022.

      Unfamiliarity with these 2 agents and concerns related to institutional departmental workflows prompted primary care physicians to seek education from pharmacists. The result was development of an educational program for primary care teams with the fundamental goal of augmenting medication awareness and accessibility for patients. Herein we provide an account and model of how pharmacists’ educational efforts effectively enhance physician and advanced practice provider comfort in prescribing oral COVID-19 antivirals and their understanding of current workflows and protocols at the institution.
      The risk of hospitalization or death from moderate to severe COVID-19 has been shown to be reduced by 50% with molnupiravir and by 89% with nirmatrelvir-ritonavir when therapy is initiated within 5 days of symptom onset.
      • Hammond J
      • Leister-Tebbe H
      • Gardner A
      • et al.
      Oral nirmatrelvir for high-risk, nonhospitalized adults with COVID-19.
      ,
      • Jayk Bernal A
      • Gomes da Silva MM
      • Musungaie DB
      • et al.
      Molnupiravir for oral treatment of COVID-19 in nonhospitalized patients.
      Both medications interfere with viral replication. Nirmatrelvir-ritonavir interferes with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) main protease, preventing processing of polyprotein precursors, whereas molnupiravir metabolites are incorporated into viral RNA, resulting in viral genome errors. Adverse effects with these medications are comparable to placebo, and the medications likely have a more favorable tolerability profile than the existing COVID-19 vaccines. Common adverse effects include dysgeusia, nausea, diarrhea, headache, and muscle pain.
      • Wen W
      • Chen C
      • Tang J
      • et al.
      Efficacy and safety of three new oral antiviral treatment (molnupiravir, fluvoxamine and Paxlovid) for COVID-19a meta-analysis.
      The pharmacist's role has evolved in the past decade to support the growing needs of patient care, an aging geriatric population, and overall physician scarcity.
      • Jaam M
      • Naseralallah LM
      • Hussain TA
      • Pawluk SA.
      Pharmacist-led educational interventions provided to healthcare providers to reduce medication errors: A systematic review and meta-analysis.
      • Hartkopf KJ
      • Heimerl KM
      • McGowan KM
      • Arndt BG.
      Expansion and evaluation of pharmacist services in primary care.
      • Truong H
      • Kroehl ME
      • Lewis C
      • et al.
      Clinical pharmacists in primary care: provider satisfaction and perceived impact on quality of care provided.
      Instead of fulfilling their historical role as dispensing medication, pharmacists now embody the role of clinicians within complex specialties, including family medicine and primary care.
      • Hartkopf KJ
      • Heimerl KM
      • McGowan KM
      • Arndt BG.
      Expansion and evaluation of pharmacist services in primary care.
      Beyond their direct patient care role, pharmacists benefit physician—and team—education and knowledge, which benefits the overall quality of the team's patient care.
      • Musselman KT
      • Moczygemba LR
      • Pierce AL
      • Plum MF
      • Brokaw DK
      • Kelly DL.
      Development and Implementation of clinical pharmacist services within an integrated medical group.
      ,
      • Pestka DL
      • Paterson NL
      • Brummel AR
      • Norman JA
      • White KM.
      Barriers and facilitators to implementing pharmacist-provided comprehensive medication management in primary care transformation.
      A systematic review and meta-analysis by Jaam et al
      • Jaam M
      • Naseralallah LM
      • Hussain TA
      • Pawluk SA.
      Pharmacist-led educational interventions provided to healthcare providers to reduce medication errors: A systematic review and meta-analysis.
      established that pharmacist educational programs are pivotal interventions that significantly decrease medication error rates, which can be sustained with subsequent educational programs (unlike single programs without continued follow-up or frequency of education). Indeed, the benefits of pharmacists’ involvement extend beyond patient education to team-based learning. This is particularly true for medication information as new therapies become available for emerging and existing diseases.
      • Amin S
      • McKeirnan KC.
      The physician perspective on pharmacist-physician collaboration and trust.
      More recently, with clinical knowledge of oral antiviral therapies for COVID-19, pharmacists have become experts in management of a new complex disease.
      • Hughes DM
      • Mordino J.
      Pharmacist responsiveness and readiness for oral antivirals for COVID-19: a rebuttal to the AMA statement regarding the Biden administration's test-to-treat plan.
      Our institution's primary care teams were provided with a pharmacist-led educational program for the use of new COVID-19 antivirals according to the 4 core pillars of our developed Model of Education (efficacy, administration, availability, and affordability). The purpose of this model was to help the primary care teams understand the new medication workflow and the key logistical considerations discussed during the educational program that would effectively and efficiently promote physician knowledge of the 2 oral therapeutics (Figure).
      Figure
      FigurePharmacist-led oral COVID-19 physician education. COVID = coronavirus disease.
      Antiviral efficacy was reviewed and presented according to the available primary literature, data, and study results, which are some of the key elements that physicians have found to be valuable when pharmacists make clinical recommendations.
      • Amin S
      • McKeirnan KC.
      The physician perspective on pharmacist-physician collaboration and trust.
      Medication administration included not only an overview of proper prescribing recommendations and patient eligibility criteria but also workflow optimization focused on diagnosis, drug selection, and patient education. Furthermore, medication availability and concurrent stock status within our institution's outpatient pharmacies were provided to the primary care teams. Medication affordability considerations were also discussed to address concerns for medication cost coverage. These 4 principles served as the knowledge foundation for the learners to reference beyond the educational program when tailoring individualized medication therapy for patients.
      In addition to providing educational programs, pharmacists can be further integrated within a complex practice like primary care.
      • Pestka DL
      • Paterson NL
      • Brummel AR
      • Norman JA
      • White KM.
      Barriers and facilitators to implementing pharmacist-provided comprehensive medication management in primary care transformation.
      As mentioned, pharmacists are valuable team members because they are drug experts who can share their knowledge with their colleagues.
      • Truong H
      • Kroehl ME
      • Lewis C
      • et al.
      Clinical pharmacists in primary care: provider satisfaction and perceived impact on quality of care provided.
      Thus, collaboration and the opportunity to build trust through knowledge sharing, professional respect, and team communication are key aspects of pharmacist integration within a team.
      • Amin S
      • McKeirnan KC.
      The physician perspective on pharmacist-physician collaboration and trust.
      A focus on eradicating barriers for these opportunities is imperative when putting the needs of the patient first.
      This educational program highlights one of many ways that pharmacists can use their skills as medication information experts. Future possible collaboration and integration opportunities, including educational programs for guideline updates and for new medication therapies as they emerge, are other ways that pharmacists can share their clinical knowledge to provide a more rounded team-based approach to patient care.
      • Hartkopf KJ
      • Heimerl KM
      • McGowan KM
      • Arndt BG.
      Expansion and evaluation of pharmacist services in primary care.
      ,
      • Truong H
      • Kroehl ME
      • Lewis C
      • et al.
      Clinical pharmacists in primary care: provider satisfaction and perceived impact on quality of care provided.
      ,
      • Amin S
      • McKeirnan KC.
      The physician perspective on pharmacist-physician collaboration and trust.

      Acknowledgment

      Randall J. Fritz, DVM, Mayo Clinic, substantively edited the manuscript. The Scientific Publications staff at Mayo Clinic provided proofreading, administrative, and clerical support.

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