PSHP 2026 Residency Conference

Purpose: Rheumatoid arthritis (RA) has persistent barriers to care, and pharmacists may help bridge these gaps. The purpose of this project was to evaluate the impact of clinical pharmacist integration in an outpatient rheumatology clinic.
Methods: A retrospective quality improvement project which reviewed interventions conducted by a clinical pharmacist embedded within Penn Rheumatology Washington Square. Patients included adults with RA with a documented intervention by the pharmacist, and those who were seen only for non-RA conditions were excluded. The primary outcome was change in RA disease activity as measured by the Routine Assessment of Patient Index Data 3 (RAPID3) at 1 and 3 months post-intervention. Secondary outcomes included the type, frequency, and time associated with pharmacist interventions, as well as changes in Clinical Disease Activity Index (CDAI) scores. This project was reviewed and determined to qualify and approved as quality improvement by the University of Pennsylvania’s Institutional Review Board.
Results: Of 25 patients with a documented clinical pharmacist intervention, all were included for analysis. Among patients with available RAPID3 data, the mean difference in RAPID3 scores from baseline to 1 month following pharmacist intervention was -2.27 (p = 0.068, n = 6) and from baseline to 3 months was 0.57 (p = 0.838, n = 12). The clinical pharmacist completed 182 interventions during the project period. The most common interventions included patient education, drug interaction checks, clinical and laboratory monitoring, comprehensive medication reviews, and medication list reviews. Time associated with interventions varied by subtype. No CDAI scores were documented at baseline or follow-up.
Conclusion: Although no statistically significant changes in RA disease severity were observed, integrating a clinical pharmacist into a rheumatology clinic yielded numerous meaningful, medication-focused interventions addressing known barriers to RA care. Findings highlight clinical and operational value of pharmacists in multidisciplinary rheumatology care, and an opportunity to standardize disease activity monitoring and enhance future outcome assessment.

Purpose: The purpose of this study was to determine whether the use of continuous glucose monitoring (CGM) in patients enrolled in a type 2 diabetes management program led to a significant change in glycemic control.


Methods: This retrospective chart review included adult patients with type 2 diabetes enrolled in a Population Health clinical pharmacist-led diabetes management program operating under a collaborative practice agreement at Lehigh Valley Physician Group (LVPG) sites between July 1, 2024 to March 31, 2025. Eligible patients were adults (≥ 18 years of age) with uncontrolled type 2 diabetes managed by their primary care provider. Eligible patients had a baseline hemoglobin A1c (HbA1c) drawn within 30 days of enrollment in the program, and at least 1 repeat HbA1c drawn during the study period. Patients were excluded if they had a diagnosis of type 1 diabetes, were pregnant, were managed by Endocrinology, or lacked a repeat HbA1c. The two study groups included patients using CGM and those who did not use CGM. 


Results: The research data report generated a total of 251 unique patient charts for review, of which 105 met at least one exclusion criteria. The remaining 146 patient charts were included in the final analysis. The study population was 58.22% male (n=85), 76.03% White or Caucasian (n=111), with a mean age of 60.68 years. The CGM group included 54 patients while the non-CGM group included 92 patients using a glucometer or no glucose-monitoring device. In both groups, HbA1c decreased significantly from baseline to repeat (p<0.0001). The reduction was greater in the CGM group (median -1.70) compared with the non-CGM group (median -1.50). This difference did not reach statistical significance (p=0.2036).


Conclusion: This analysis supports that pharmacist-led interventions can result in HbA1c reduction. Both CGM and non-CGM users experienced significant improvements in glycemic control. Although the median reduction in HbA1c was greater among CGM users, this difference was not statistically significant. A larger study over a longer period of time could further evaluate whether CGM use impacts glycemic control in our patient population.   

Purpose: Warfarin monitoring of the international normalized ratio (INR) within a narrow range is assessed by time in therapeutic range (TTR). This study evaluates whether glucagon-like peptide-1 (GLP-1) agonists impact TTR in stable patients.


Methods: This retrospective cohort study included adult patients managed at an anticoagulation clinic at the University of Pennsylvania Health System who were on stable warfarin therapy and initiated a GLP-1 agonist between January 2023 and September 2025. Patients required ≥3 values and documented targets in 6-month pre/post periods. Exclusions included unstable therapy, insufficient data, anticoagulant changes, or therapy discontinuation. The primary endpoint was change in TTR from baseline to 6 months post-initiation. Secondary endpoints included percentage of INRs within range, frequency of warfarin dose interventions, bleeding events, and weight change at 6 months. Data was collected via electronic records and REDCap. The primary endpoint was analyzed using a Wilcoxon signed-rank test; secondary endpoints were summarized descriptively.


Results: A total of 52 patients were included. Median TTR decreased from 91.6% pre-initiation to 86.6% post-initiation (p=0.107), which was not statistically significant. Few bleeding events were observed (n=2). Patients experienced a significant reduction in weight at 6 months (mean change −7.3 kg, p<0.001). Data on INR within range and dose interventions showed variability, but no clear pattern of increased instability.


Conclusion: Initiation of GLP-1 agonists in stable warfarin patients was not associated with a statistically significant change in TTR, though a numerical decline was observed. Concurrent use is well tolerated, with minimal bleeding events and significant weight loss. Findings suggest that safe warfarin therapy may be maintained with GLP-1 initiation, though close INR monitoring remains prudent. Larger studies are needed to further clarify this relationship.


IRB Approval: Protocol Number - 859543

Purpose:
To determine whether initiating a glucagon-like peptide (GLP) receptor agonist (GLP)in adults with hypothyroidism on a stable levothyroxine regimen leads to a change in levothyroxine requirements.


Methods:
A retrospective study was conducted by chart review using electronic health records at Penn Medicine Lancaster General Health from July 2020 to June 2024. Patients were included if they were at least 18 years of age, diagnosed with hypothyroidism, on a stable dose of levothyroxine prior to initiation of a glucagon-like peptide receptor agonist continued for at least 6 consecutive months, and at least 1 thyroid-stimulating hormone level within 6 months before and after a glucagon-like peptide receptor agonist. The primary endpoint is change in levothyroxine dose at 6 months after initiation of a glucagon-like peptide receptor agonist. Secondary endpoints include percentage weight loss at 6 months, change in thyroid-stimulating hormone at 6 months, change in levothyroxine dose at 12 months, and percentage of weight loss compared to percentage change in levothyroxine at 6 months.


Results:
Among 136 patients, 18 (13.2%) had a levothyroxine dose change within 6 months of glucagon-like-peptide receptor agonist initiation. Firth logistic regression found no significant associations between dose change and glucagon-like-peptide receptor agonist type, age, sex, smoking status, or weight change (all p>0.05). Secondary analysis showed patients with levothyroxine dose changes had greater reductions in thyroid-stimulating hormone at 6 months versus those without changes (median -1.69 vs 0.00 mIU/L; p=0.015). At 12 months, weight change did not differ between groups requiring levothyroxine adjustment and those without adjustment (p=0.790).


Conclusion:
Glucagon-like-peptide receptor agonist initiation was not associated with predictable changes in levothyroxine requirements based on baseline patient factors or weight loss. However, greater reductions in thyroid-stimulating hormone were associated with levothyroxine dose adjustments, suggesting thyroid function should be monitored after glucagon-like-peptide receptor agonist initiation. Larger studies are needed to confirm these findings.


IRB APPROVAL:
PENN IRB Protocol #: 859751; approved 11/16/2025

Purpose:
Sulfonylureas (SU) increase risks of hypoglycemia, weight gain, and uncertain long‑term glycemic control. This project evaluates how Clinical Pharmacy Practitioners (CPPs) improve diabetes care by deprescribing SUs and optimizing therapy.
 
Methods:
Patients were identified from a CMCVAMC report of those with an active SU prescription or via provider referral. CPPs then conducted comprehensive medication management visits to assess therapy and optimize diabetes care when appropriate. The primary outcome was the change in reported hypoglycemia before and after CPP interventions. Secondary outcomes included changes to preferred agents, A1c, and weight. Patients were included if they are ≥60 years old, have an A1c ≤10.5%, have an active VA or non‑VA prescription for glipizide, glimepiride, or glyburide, and were identified as at risk for adverse outcomes from SU use. A follow‑up assessment of SU use occurred with the CPP or Primary Care Physician (PCP) at least once. Patients were excluded if they receive hospice care, are under 60 years old, or have an A1c >10.5%.
 
Results:
The population was predominantly male and white, with 41.9% having baseline CKD and 51.2% having ASCVD. Most participants were overweight or obese. All patients (100%) were initially receiving a SU, alongside varying use of metformin, SGLT2 inhibitors, DPP‑4 inhibitors, GLP‑1 agents, and insulin therapies. Hypoglycemia was reported by 32.6% at baseline and after interventions the incidence declined to 7.4%. Following CPP review, 51.8% had the SU discontinued, 12.9% had dose reduction, and 10.6% were instructed to take the medication before meals, while 27.1% had no intervention. The final regimen demonstrated shifts toward metformin (63.4%), SGLT2 inhibitors (64.6%), and GLP‑1 agents (25.6%), with SU use decreasing to 41.5%.


Conclusion:
Interventions targeting SU therapy led to regimen optimization and a reduction in hypoglycemia. Increased uptake of metformin, SGLT2 inhibitors, and GLP‑1 therapies reflects improved safety and closer adherence to guideline‑preferred treatments, highlighting the value of proactive medication review performed by CPPs.

This study examines the confidence of advanced pharmacy practice experience students in prescribing medications after graduation and the teaching strategies influencing their confidence.
A Qualtrics survey was sent to APPE students at 19 pharmacy schools to assess their confidence in prescribing medications as future pharmacists. The Likert-scale survey measured prescribing confidence, teaching strategies, work experience, demographics, and post-graduation plans. Data collection runs from 3/16/2026 to 5/16/2026. Descriptive statistics will evaluate prescribing confidence, and ordinal regression will analyze the association between teaching strategies on prescribing confidence. This study received IRB approval from Saint Joseph’s University.


Data collection is ongoing. As of 04/10/2026 a total of 154 students responded with 67.97% feeling confident to prescribe upon graduation. Among those reporting prescribing confidence, cardiovascular 14.40% and gastrointestinal 13.62% diseases had more than 10% of students reporting prescribing confidence. Teaching strategies respondents selected as extreme contributors to their confidence include experiential learning 67.80%, case-based learning 29.66%, independent study 20.34%, role-play 19.49%, didactic learning 15.25%, team-based learning 11.02%, and flipped classroom 10.17%. Additionally, 59.32% reported needing more training before starting a prescribing role, while 40.68% felt prepared without additional training.


Preliminary analysis suggests that a majority of students feel confident prescribing medications upon graduation and attribute this confidence most often to experiential learning. Students who felt confident prescribing also felt more confident prescribing medications for cardiovascular and gastrointestinal diseases. More students feel more training is needed before starting a prescribing role.


IRB Approval: Approved January 26, 2026 by the Saint's Joseph's University IRB

Purpose: The purpose of this retrospective study is to evaluate the appropriateness and effectiveness of low-intensity pravastatin 20 mg daily in statin-naïve, kidney transplant recipients, according to the estimated baseline ASCVD risks.
Methods: The study includes a chart review of 296 subjects who underwent kidney transplants between September 1, 2023, and September 1, 2024, with at least 12 months of post-transplant follow-up. Baseline demographics that are pertinent to estimate ASCVD risk are included. Transplant data was collected, including transplant indication, lipid profiles, and incidence of delayed graft function. Goal statin intensity was extrapolated based on age, history of diabetes mellitus, chronic kidney disease, tobacco use, coronary calcium scores (when available), and calculated ASCVD scores. ASCVD risk scores were assessed using the American College of Cardiology online calculator. Pravastatin initiation and monthly continuation were recorded. If pravastatin discontinuation occurred within 12 months, timing, reason for discontinuation, and intensity changes were further assessed. Information on immunosuppressive therapy was also collected.
Results: A total of 296 patients were evaluated, and 60 patients were included for analysis. The 10-year ASCVD risk was estimated for 24 (40%) patients. Low-intensity pravastatin was appropriate in 35 (58%) patients. The median changes in LDL, HDL, and total cholesterol levels from day 30 to 365 post-transplant were 7.5 mg/dL, 1.5 mg/dL, and 10 mg/dL, respectively (all p-value>0.05). Approximately 51 (85%) patients continued pravastatin throughout one year post transplant. Four (6.7%) discontinued pravastatin due to reported intolerance or self-discontinuation; no patients met clinical criteria for hepatoxicity and rhabdomyolysis. One (1.7%) experienced non-fatal myocardial infarction (MI); however, no patients experienced ischemic stroke. 
Conclusion: We estimated that more than a third of patients might be considered for a higher intensity statin based on baseline characteristics, estimated risk assessment, and ASCVD risk enhancers. Most patients remained on low-intensity pravastatin for up to one-year post-transplant. Changes in lipid profile from 30 days to 365 days were not significant. No major safety issues were observed, except for non-fatal MI. 

Purpose
To evaluate the impact of a pharmacist-led intervention on inappropriate beta-blocker prescribing in adults with essential hypertension (HTN) without compelling indications
Methods
A prospective cohort study of adults with essential HTN who were prescribed a beta-blocker without a compelling indication was conducted across eight family medicine practices at our institution. A randomized convenience sample (N≈120) was identified from a prior medication use evaluation. After chart review, recommendations were sent to the primary care practitioner (PCP) to deprescribe the beta-blocker or switch to a guideline-preferred agent. Patients were excluded for resistant HTN, documented ASCVD, heart failure, recent myocardial infraction, arrhythmias, migraine, hyperthyroidism, intolerance to first-line agents, or cardiology-managed HTN. The primary endpoint was the recommendation acceptance rate. Secondary outcomes were absolute change in inappropriate beta-blocker use, time to implementation, predictors of acceptance, and documented adverse drug events. Descriptive statistics were used.
Results
A total of 25 patients met inclusion criteria. Eleven (44%) recommendations to deprescribe were accepted. Among accepted recommendations with follow-up (n = 6), 3 were implemented. Twelve (48%) recommendations were refused, and 2 (8%) received no response. The most common reason for refusal was that the beta-blocker had been initiated by a specialist (n = 11). Reported adverse drug reactions potentially related to beta-blockers (N = 26) consisted of fatigue (n = 14), bradycardia (n = 4), and sleep disturbances (n = 8). Male sex was associated with lower odds of recommendation acceptance (OR, 0.14; 95% CI, 0.02–0.84; P = 0.032).
Conclusion: to be presented at the conference

Purpose: 
This retrospective cohort study characterized approaches for resuming semaglutide or tirzepatide after at least two consecutive missed doses and evaluated tolerability in outpatient clinics at Penn Presbyterian Medical Center (PPMC).


Methods: 
This study included adults who missed at least two consecutive doses of semaglutide or tirzepatide between October 2024 and November 2025 and reinitiated therapy at a non-starting dose. Exclusion criteria included patients who resumed at the lowest dose, those switching medications (except brand substitutions), or without follow-up data. Chart review captured demographics, indication, therapy duration before lapse, prior and resumed doses, and number of missed doses. The primary outcome was the tolerability associated with the dose step changes related to missed doses. Tolerability was defined as no patient-reported adverse drug reactions (ADRs), a dose increase or continuation. Intolerance was defined as any patient-reported ADR, a dose reduction, or discontinuation. Secondary outcomes included reasons for lapse and months saved by avoiding restart at the initial dose. Descriptive statistics were used.


Results:
Among 65 patients, the mean age was 46 years and 76.9% were female. Most were prescribed tirzepatide (46.2%) or semaglutide (38.5%) for weight loss. The median number of missed doses was 3 (IQR, 2 to 4), with a median dose step change of -1 (IQR, -2 to 0). A dose reduction occurred in 37 patients (57%), 24 patients (36.9%) had no change, and 4 patients (6.2%) had a dose increase. Overall, 95.4% of patients tolerated reinitiation. Access-related issues accounted for 87.7% of lapses. The median months saved by avoiding restart at the initial dose was 2 (IQR, 1 to 3). Additionally, tolerability remained high across missed-dose subgroups.


Conclusion: 
Resuming semaglutide or tirzepatide at a non-starting dose after at least two missed doses was well-tolerated in most patients. Dose reductions were common with high rates of tolerability. This approach prevented titration delays typically caused by missed doses. Further studies should prospectively evaluate optimal reinitiation strategies, including the impact on long-term weight loss and glycemic control.

Purpose:
The purpose of this study was to compare the number of patients who had appropriate lipid panel follow-up/monitoring at TUHS divided by management type: managed by pharmacy (Rx-managed) and not managed by pharmacy (Non-Rx-managed).


Methods:
This study was conducted at the Temple Internal Medicine Associates (TIMA) clinic at TUHS from 07/01/2024 to 06/30/2025. Inclusion criteria were age ≥18 years, TIMA patients, ≥2 in-person visits (≥3 months apart), and ≥1 lipid panel during the study period. Exclusion criteria included ESRD, palliative care, pregnancy, TSH >4.5 mIU/L, or TG >400 mg/dL. Patients were categorized as Rx-managed (≥2 pharmacist visits) or Non-Rx-managed (managed exclusively by non-pharmacist clinicians). The primary endpoint was the number of lipid panels. Secondary endpoints included mean LDL-C, number of patients achieving LDL-C <100 mg/dL and <70 mg/dL, and number of patients receiving lipid-lowering therapy. Due to group size differences, 1:4 propensity score matching was performed using age, sex, race, T2DM, and ASCVD. Continuous variables were analyzed using the Wilcoxon rank-sum test, and categorical variables using Fisher’s exact or Chi-square tests.


Results:
Baseline characteristics were similar between groups after 1:4 matching. A greater proportion of patients in the Rx-managed group had more than one lipid panel compared with the Non-Rx-managed group (39.7% vs 27.1%, p=0.006). Mean LDL-C was numerically lower in the Rx-managed group (86.6 vs 88.4 mg/dL), though not statistically significant. The proportion of patients achieving LDL-C goals was similar between Non-Rx-managed and Rx-managed groups (<100 mg/dL: 67.1% vs 70.2%; <70 mg/dL: 34.3% vs 38.8%). Use of lipid-lowering therapy was comparable between groups. This study used real-world data and propensity matching to improve comparability; however, it was limited by its retrospective, single-center design and lack of baseline lipid values.


Conclusion: 
Patients in the Rx-managed group were more likely to receive additional lipid monitoring than those in the non-Rx- managed group. Although not statistically significant, the Rx-managed group showed trends toward lower LDL-C and greater goal attainment. Future studies with longer follow-up and baseline lipid values are needed to better evaluate longitudinal lipid outcomes and the clinical impact of pharmacist-led management in lipid management.