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Optimizing the Practice Advancement Initiative PAI at the State Level

Webinar Slide Deck

PAI link to the ASHP  webinar recording.


2016 Catch the Wave Poster Abstracts
NOTE: Poster presenters who are CSHP members and were present at the 2016 Catch the Wave conference.

"Use of four factor prothrombin complex concentrate for mitigation of rivaroxaban-induced bleeding in emergent coronary artery bypass graft procedure"
Presented by Ahmad J. Badwan, 2016 PharmD Candidate, USJ School of Pharmacy (Co-authors: Elizabeth M. Tencza, 2016 PharmD Candidate, UConn School of Pharmacy; Michael H. Liu, PharmD, BCNSP, BCPS, Yale New Haven Hospital)

Currently, there is no guideline recommendation or a true reversal agent for the novel oral anticoagulants (NOACs).  New FDA-approved blood products, like 4 factor-prothrombin complex concentrate (4-PCC), are thought to decrease the bleeding severity from NOACs by supplementing the clotting cascade to overcome the drug effect. Furthermore, there is minimal information available regarding the use and monitoring of these new products for emergency surgeries. To our knowledge, this is the first published case for the use of 4-PCC for the mitigation of bleeding in a patient on rivaroxaban for emergent on-pump coronary artery bypass graft (CABG).

The patient is a 69-year-old Caucasian male with a history of CAD, prior coronary stents, and chronic non-valvular atrial fibrillation. He developed angina and was admitted at an outside facility after the pain intensified. He deteriorated overnight and was sedated and intubated. Emergent left heart catheterization for STEMI was performed and revealed thrombosis of left anterior descending coronary artery (LAD) stent. In addition to his long term dual antiplatelet and rivaroxaban 20mg oral daily therapies (adhered to therapies with the last dose given at that facility in the morning) he had also received bivalirudin and heparin IV.  He was stabilized with an intra-aortic balloon pump and transferred to our facility via air ambulance at 10:41 for emergent on-pump CABG. At 11:36, PT/INR=14 seconds/1.32, Hgb=13.2g/dL, platelet=241,000cells/mm3. The patient was given 2,500units (30 units/kg) IVPB of 4–PCC at 200units/min at 13:13. At 14:54, PT/INR=12.2 seconds/1.13. The CABG procedure began at 16:13 and ended at 20:20. A total of 39,000units of heparin IV was administered intraoperatively. Post-operatively, he received protamine 250units IV at 18:57. At 20:32, PT/INR=15seconds/1.42, Hgb=10.7g/dL, and platelet=238,000cells/mm3. The patient was extubated on POD2, transferred to the cardiothoracic stepdown unit on POD7 and subsequently discharged on POD8 without any complications.

Based on the 2014 data on on-pump CABG from the Society of Thoracic Surgeons (STS) of similar institutions, the patient had a similar hospital length of stay (7 days vs. STS median of 8 days), and time on mechanical ventilation when compared to isolated CABG (48 hours vs. STS median of 68 hours, respectively).

We report the first known case of the use of 4-PCC for emergent CABG in a patient who was administered rivaroxaban. More case reports and case control studies are needed to further evaluate the use of 4-PCC in mitigating rivaroxaban-induced bleeding in other emergent surgeries.     

" Pharmacist role in prescriber education following a drug reformulation and the pharmacological and financial impact of appropriate dosing in a unified correctional managed health system "
Presented by Audrey R. Corman, PharmD, UConn CMHC Pharmacy
Currently there are four commercially available oral formulations of mesalamine DR.   Each formulation has dosing regimens and maximum daily dose that are specific to each individual product. When multiple formulations of a drug product exist and a reformulation of one or more of these products occurs prescribers are often unaware of the pharmacological and financial impact of these changes. Prescriber education provided by the pharmacist can encourage communication and awareness of drug therapy optimization and encourage cost savings.
During final pharmacist checks of patient medication packets and upon further investigation it was noted that there were discrepancies in mesalamine DR dosing regimens. The pharmacists:
1.  Developed and ran MS access queries in the pharmacy order entry system to identify all current mesalamine DR orders
2. Analyzed data to determine which orders could be optimized based on product package insert guidelines
3. Developed a chart to educate prescribers on the various mesalamine products and regimens
4. Emailed prescribers this chart and recommended order changes be rewritten to optimize therapy.
Upon review 40 patients were identified as being on Delzicol (mesalamine DR) treatment, 14 of which were identified as being above the daily maximum recommended dose. The doses identified as being above the maximum recommended dose ranged from 3200mg to 4800mg daily. Of the 14 identified regimens only 1 existing and 1 new regimen was optimized by prescribers based on pharmacist recommendations.
Prescribers were receptive to pharmacist suggestions and while many regimens remained unchanged some were optimized based on the information provided, resulting in a savings of $5694/yr. Had all regimens been optimized as suggested a cost savings of $77,818 could have been achieved. Continued prescriber education and follow up by pharmacists is required in situations of drug product reformulation to help optimize patient therapies as well as reduce financial burdens.
" Cost-effectiveness of high-dose edoxaban compared to warfarin for stroke prevention in non-valvular atrial fibrillation patients "
Presented by Florence Okeny Egri, MS, PharmD Candidate 2017, UConn School of Pharmacy
High-dose edoxaban is United States (US) Food and Drug Administration approved to reduce the risk of stroke in non-valvular atrial fibrillation (NVAF) patients with a creatinine clearance (CrCl) ?95 mL/minute.  The cost-effectiveness of high-dose edoxaban in these patients has not been assessed.
In this analysis we sought to estimate the quality-adjusted life years (QALYs), costs, and cost effectiveness of high-dose edoxaban compared with adjusted-dose warfarin in patients with NVAF and a CrCl ?95 mL/minute.
A Markov model was created to compare the cost-effectiveness of high-dose edoxaban and adjusted-dose warfarin in patients with CrCl ?95 mL/minute. The model was performed from a US societal perspective; and assumed patients initiated therapy at 70-years-old, had a mean CHADS2 score=3 and no contraindications to anticoagulation. Data sources included renal subgroup analysis of the Effective Anticoagulation with Factor Xa Next Generation in Atrial Fibrillation (ENGAGE-AF) trial and other published studies. Outcomes included lifetime costs (2014 US$), quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratios.  The robustness of the model’s conclusions was tested using one-way and 10,000 iteration probabilistic sensitivity analyses (PSA).
Patients treated with high-dose edoxaban lived an average of 10.50 QALYs at a lifetime treatment cost of $99,833 compared to 10.11 QALYs and $123,516 for those treated with adjusted-dose warfarin; making high-dose edoxaban an economically dominant strategy.  The model’s conclusions were found to be robust upon one-way sensitivity analysis. PSA suggested high-dose edoxaban was economically dominant compared to adjusted-dose warfarin in >99% of the 10,000 iterations run.
This Markov model suggests high-dose edoxaban may be an economically dominant strategy when compared to adjusted-dose warfarin for the prevention of stroke in NVAF patients with a CrCl ?95 mL/minute and an appreciable risk of stroke.

" Medication reconciliation pilot collaboration between a community intake jail and an academic medical center correctional managed care pharmacy"
Presented by Michael D. Kimmel, PharmD (Co-authors: Robyn Wahl, PharmD; Marti Barman, PharmD); UConn CMHC Pharmacy
Upon incarceration a patient’s first point of contact with correctional health care is either a nurse, or a social worker.  These individuals document the initial medication history.  The offender and the intake staff may not be familiar with drug information leading to potential medication errors.   According to ASHP-APhA Medication Reconciliation Initiative Workgroup, “Medication reconciliation is the comprehensive evaluation of a patient’s medication regimen any time there is a change in therapy in an effort to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions, as well as to observe compliance and adherence patterns.” Medication reconciliation should be done at every transition of care in which new medications are processed or when existing medications orders are rewritten.   On an average day two to four newly incarcerated inmates require medication reconciliation in our organization.  To avoid medication errors the pharmacy started a medication reconciliation pilot program in collaboration with a community intake jail.   
Since March 2015 Correctional Managed Health Care (CMHC) pharmacy has been engaged in medication reconciliation with a community intake jail.  The process at CMHC pharmacy includes the following five steps:  
  • Pharmacy receives a list of newly admitted patients including the patient’s identifying information, self-reported medications and community pharmacy contact information daily.
  • An Advanced Practice Pharmacy Experience (APPE) student, pharmacy resident or staff pharmacist contacts the community pharmacy verifying medication list and other pertinent information.
  • The list is reviewed for non-formulary medications, interactions, duplications, adherence problems etc. and formulary alternatives are offered for any non-formulary drugs.
  • The reconciled list and pharmacist’s recommendations are emailed to the intake team which includes a psychiatrist, physician assistant, nurse supervisors and health service administrator.
  • The pharmacy documents medication reconciliation interventions in the pharmacy information system.
  • 100% of pharmacist therapeutic medication  recommendations were accepted
  • Increased formulary compliance evidenced by decreased number of non-formulary requests
  • Decreased time form orders to medication delivery because formulary medications are available on site in the jail
  • Pharmacist medication reconciliation is well received by jail  health services staff from administration to intake staff to physicians
Medication reconciliation is a step by step process that when done correctly and accurately can prevent numerous prescribing and medication errors.  CMHC’s future opportunities include expansion of the medication reconciliation pilot to all Connecticut community intake jails.

"A comparison of the incidence of flushing with immediate release niacin in combination with various aspirin formulations"
Presented by Alexander Levine, 2016 PharmD Candidate, USJ School of Pharmacy
We hypothesized that taking niacin simultaneously with different forms of aspirin would prove to effectively reduce flush over niacin plus placebo. A traditional strategy has been to take enterally absorbed aspirin 30 minutes before niacin, which has been shown to reduce flushing by 30-50%. However, this administration is challenging for patients.  Our objective was to study the efficacy of enterally absorbed and oral mucosa absorbed aspirin to reduce flush when taken at the same time as niacin.
In this prospective, double blinded, placebo controlled, cross-over, randomized control trial, aspirin or placebo was given in both chewed (orally absorbed) and swallowed (enterically absorbed) formulations with co-administration of 1000 mg of niacin. Subjects then evaluated the degree of flush symptoms on a validated scale.
Administration of swallowed aspirin and niacin simultaneously reduced moderate to severe flushing events by 36.1% from 2.35 flushes per subject to 1.5 flushes per subject (p=0.003). Similarly, the formulations that had only oral mucosa absorbed aspirin, and also half oral/half enteral aspirin absorption reduced flush by 32.9% (p=0.003) and 32.9% (p=0.003) respectively. In the subset of subjects who experienced moderate to severe flushing symptoms despite taking a swallowed aspirin, there was a further decrease in flushing by 20.5% from 2.12 flushes per subject to 1.72 flushes per subject (p=0.05) with the oral mucosa aspirin formulation, and an 18.0% decrease for the half oral mucosa absorbed and half enteral formulation (p=0.03).
Given simultaneously, novel formulations of aspirin and niacin, which include oral mucosa absorbed aspirin, are effective in reducing flush, and represent a more tolerable alternative to the existing niacin formulations on the market. They have the potential to improve tolerability and compliance for the patient populations who would benefit from high dose niacin therapy.

"Utilization of therapeutic interchange to improve access to medication in a low income uninsured population"
Presented by Christine Toni, RPh, Hope Dispensary of Greater Bridgeport
Literature reports in the general population show 21.6-28% prescriptions are not filled. 1,2   Cost of medication has been shown to decrease medication access in low income un-insured populations 2.  This study was to evaluate the impact of a formulary system and therapeutic interchange in a non-profit charitable pharmacy to increase medication access for specific chronic disease medications.
  • Developed formulary based on formularies utilized by area hospitals and chronic diseases most served by the pharmacy.
  • Established collaborative practice agreement with area clinic physicians allowing pharmacist to dispense from available stock using approved therapeutic interchanges.  
  • Contacted other providers (PAs, APRNs, NPs, non-collaborative physicians) for consent to interchanges.
  • Adjusted pharmacy inventory based on availability of evidence-based medication at lowest cost to pharmacy.  
  • Distributed formulary and changes to clinics and key practices monthly
  • Measured number and type of collaborative and therapeutic recorded in patient record over one month (July, 2015).
  • Compared patient cost of prescribed medication from a local discount pharmacy to that of interchange medication from charitable pharmacy.
  • Reviewed medication categories of interchanged meds.
  • Examined sourcing of interchanged meds and impact on pharmacy budget of meds provided.
  • 7 collaborative interchanges resulted in medications being dispensed upon patient initial visit
  • 54 therapeutic interchanges made resulting in patients being able to receive medication at no cost from the charitable pharmacy
  • $8,819.22 savings to patients related to changes made.  Average savings of $144.58/ prescription
  • Statins, ARBs and PPIs were the most common interchanges that occurred at the charitable pharmacy.

"Adverse effects of incretin–based therapies on major cardiovascular and arrhythmia events: Meta-analysis of randomized trials"
Presented by Fei Wang, RPh, MSc, PharmD, BCPS, FASHP; University of Connecticut
The cardiovascular safety of incretin based therapies (IBTs) in type 2 diabetes from recent cardiovascular outcome trials have not demonstrated either benefit or harm in major adverse cardiovascular events (MACE). Earlier meta-analyses showed conflicting results but were limited in methodology. We aimed to perform an updated meta-analysis of all available incretin therapies on the incidence of MACE plus arrhythmia and heart failure.
Materials and Methods
We identified studies published through November 2014 by searching electronic databases and reference lists. We included RCTs in which the intervention group received IBTs and the control group received placebo or standard treatment; enrolled >100 participants in each group; interventions lasted >24 weeks; and reported data on one or more primary MACE endpoints plus terms for arrhythmia and heart failure. We used the Peto method for each CV event for individual IBT treatment.
In this meta-analysis of 100 RCTs involving 54,758 IBTs users and 48,175 controls, exenatide was associated with increased risk of arrhythmia (OR 2.83; 95% CI, 1.06-7.57); saxagliptin was associated with an increased risk of heart failure (OR 1.23; 95% CI, 1.03-1.46) and sitagliptin was associated with a significantly decreased risk of all cause death compared to active controls (OR 0.39, 95% CI 0.18-0.82).
In type 2 diabetes, exenatide may increase the risk of arrhythmia and sitagliptin may reduce the risk of all cause death, however, the subgroup of patients most likely to experience harm or benefit is unclear. 
" Determining routine product checking benchmarks at an academic medical center"
Presented by Ashley M. West, PharmD Candidate 2016 (Co-author: Alyssa J. Boutin, PharmD Candidate 2016); UConn School of Pharmacy
Due to the vast differences among pharmacy operations, administrators lack standardized benchmarks to guide improvement in operations, workflow and resource allocation. External benchmarks are standards set by outside institutions, while internal benchmarks are institution-specific and are often used as the starting point for performance improvements. A direct observation time study was conducted to determine internal benchmarks for the routine product checking tasks performed by pharmacists at an academic medical center.
Two Advanced Pharmacy Practice Experience (APPE) students alternated as independent observers in this direct observation time study. The following routine checking tasks were included: hourly runs, narcotic polls, barcoding, compounding, packaging, pediatric oral syringes, PakPlus, rapid sequence intubation kits, emergency medical service kits, and beyond use dating batches. All other pharmacist responsibilities were excluded from the study. Using a stopwatch, the total time to complete tasks was measured, pausing if the pharmacist stopped checking for an unrelated interruption. The primary aim was to determine the average percentage of time spent on checking tasks per day. Secondary aims were to assess the average percentage of time spent on individual checking tasks and identify the impact of checking tasks on the central pharmacist workflow by hour and by shift.
Data were collected for 69.5 hours over 7 days. Routine checking tasks consumed an average of 27 percent of the central pharmacist day and evening shifts. Hourly runs comprised 9.4 percent of the day, representing approximately one third of total daily checking time. Following hourly runs are PakPlus, narcotic polls, pediatric oral syringes, packaging, barcoding and compounding at 5.5 percent, 4.7 percent, 4.1 percent, 1.8 percent, 0.6 percent and 0.5 percent of the day, respectively. The peak time to complete routine checking tasks was from 0800 to 1100 on the day shift and 1400 to 1500 on the evening shift. Furthermore, the evening shift had fewer interruptions compared to the day shift, which had an inconsistent workflow.
Benchmarks are central to designing a practice model and allocating resources for maximal efficiency. This direct observation time study defined time requirements for routine checking tasks, creating reference benchmarks as tasks are added or removed and workflows redesigned and evaluated. This study design provided APPE students with unique insight into administrative and operational pharmacy while obtaining data without using pharmacy resources. This design and approach can be adapted at other institutions to determine internal benchmarks.
2015 Great Eight Residents' Showcase - Winning Abstracts
Left to right: Kristin Linder, Adam Ross, Nidhi Saraiya
Comparison of weight-based dosing versus standard-dose diltiazem in patients with atrial fibrillation presenting to the emergency department
A. Ross, M. Krawczynski, M. Drescher; Hartford Hospital, Hartford, Connecticut

Objective: Atrial fibrillation (AF) with rapid ventricular response (RVR) is a common cardiac dysrhythmia that requires many patients to seek emergency medical treatment. The current treatment guidelines suggest treating RVR using weight-based (WB) intravenous push diltiazem. There are data to suggest that a low, standard dose (SD) of diltiazem may be as effective in treating AF with RVR as WB dosing. The objective of this study is to determine if low, SD diltiazem is non-inferior to WB diltiazem in the initial treatment of AF with RVR.

Methods: This was a single-site, retrospective analysis from November 2010 to August 2014. Patients were included if they were at least 18 years of age presenting the emergency department experiencing AF with RVR, a heart rate greater than 120 beats per minute (bpm), and received a bolus dose of diltiazem as initial therapy. Patients were considered to either have received SD diltiazem (10 mg) or WB diltiazem (0.2 to 0.3 mg/kg) for initial treatment of RVR. Baseline characteristics, co-morbid conditions, concomitant medication use, onset of AF, heart rate, blood pressure, and dose of diltiazem administered were collected by manual chart review. Successful treatment was defined as any of the following: conversion to normal sinus rhythm, heart rate less than 100 bpm, or a reduction of heart rate greater than 20 percent from baseline within 15 minutes of initial bolus dose. Results were compared using chi-square tests, Student’s t-test, and logistic regression.

Results: A total of 1,183 patients were evaluated for study inclusion, 419 patients were included in the final analysis (SD diltiazem, n = 235; WB diltiazem, n = 184). Baseline characteristics were similar with the exception of weight (79.1 ± 19.9 vs. 72.7 ± 18.0 kg, p = 0.001), dose of diltiazem administered (10 ± 0.0 vs. 17.1 ± 4.4 mg; p <0.001), heart rate (144.7 ± 17.4 vs. 149.0 ± 18.2 bpm; p = 0.015), systolic blood pressure (127.7 ± 26.2 vs. 133.1 ± 27.7 mm Hg; p = 0.040), and diastolic blood pressure (80.0 ± 17.3 vs. 83.8 ± 18.9 mm Hg; p = 0.031). There were no significant differences in the rates of success between the groups (64.3 vs. 70.1%, p = 0.207). When utilizing a non-inferiority margin difference between the group proportions of 10%, SD was non-inferior to WB diltiazem dosing (OR = 1.121 vs. 1.059, difference of 6.2%). WB dosing had a statistically significant percent reduction of heart rate from baseline (28.3 ± 15.9%) compared to the SD group (24.4 ± 15.1%, p = 0.011), as well as systolic blood pressure (14.6 ± 25.2 vs. 8.8 ± 20.8%; p = 0.010). Younger age (OR = 1.055, 95% CI 1.002-1.117) and a larger percent reduction of heart rate (OR = 0.256, 95% CI 0.145-0.452) were predictors of success when evaluated in the multivariate analysis.    

Conclusions: Our retrospective, single-site study suggested that a low, SD of diltiazem is non-inferior to WB diltiazem dosing in the treatment of AF with RVR. Variables that influence the odds of success were significantly modified by age and percent reduction in heart rate.

Evaluation of corrected QT intervals in patients receiving concomitant methadone and ritonavir
N. Saraiya, M. Nailor; Hartford Hospital, Hartford, Connecticut

OBJECTIVE: Corrected QT (QTc) interval prolongation in heart rhythm is a known risk factor for cardiac arrhythmias including the potentially fatal Torsades de Pointes (TdP), and can be induced by many commonly used drugs, including methadone and ritonavir. There is a significant population of HIV-positive, opioid dependent patients in the United States who receive both of these agents chronically, but few papers discussing their combined safety. By comparing the QTc intervals of patients who take methadone and ritonavir concomitantly with patients who take either methadone or ritonavir alone, the clinical impact of the interaction between these two medications can be better understood.

METHODS: Current literature suggests that a 6 msec increase in QTc interval with a population standard deviation of 16 msec is significant. Using a one-sided alpha of 0.025 and a beta of 0.2, a sample size estimate yields that 138 patients, divided equally among the three treatment groups, should be enrolled to detect this difference. Targeting a sample size of 46 patients per arm, eligible patients were placed into one of three groups: methadone therapy, ritonavir therapy, or methadone and ritonavir concomitant therapy. After assessing all available electrocardiograms (ECGs) during the patient’s stay, the ECG with the highest QT and QTc based on Bazett’s formula was collected and recorded. Then using those numbers, QTc intervals based on Fridericia’s and the Framingham formulas were also calculated. Additionally, each patient was also evaluated for select cardiac safety endpoints, patient-specific risk factors for QTc prolongation, and other concomitant medications with known and possible risk of QTc prolongation.

RESULTS: Based on the enrolled patients, the mean QTc intervals based on Bazett’s, Fridericia’s and the Framingham correction formulas were calculated for each of the three arms (M, R, MR).


M = 466.4 ± 50.4 msec

R = 448.4 ± 57.8 msec

MR = 457.6 ± 41.6 msec


M = 446.5 ± 45.2 msec

R = 428.8 ± 48.6 msec

MR = 467.0 ± 63.3 msec


M = 410.8 ± 48.6 msec

R = 394.7 ± 48.5 msec

MR = 427.0 ± 52.4 msec

The mean values from all three arms were initially compared using the analysis of variance (ANOVA) test, with significant changes found in the QTcFridericia and QTcFramingham groups (p = 0.007, p = 0.020). To assess which two groups may be contributing to these findings, the Scheffé test was performed and for both QTcFridericia and QTcFramingham, it was found that the mean values between the R and MR arms were significantly different (p = 0.007, p = 0.021).
Safety endpoints of syncope, hypotension, new-onset arrhythmia, death, and the presence of any one of these events were assessed. No significant differences were found when comparing all three arms.

Multivariate analyses were performed to assess whether safety endpoints, patient-specific risk factors and concomitant QTc prolonging medications may have served as confounding variables. Diabetes mellitus (DM) was found to be significantly different for QTcBazett (p = 0.013) and Mg2+ < 1.8 mg/dL was significantly different for QTcBazett and QTcFridericia (p = 0.045, p = 0.039).

CONCLUSION: In the univariate analyses of our patients, adding methadone to a patient receiving ritonavir significantly increased the QTc interval. In the multivariate analyses of our patients, DM and Mg2+ < 1.8 mg/dL were associated with prolonged QTc intervals. There were no significant differences in safety outcomes, but this finding must be interpreted cautiously as this study was not powered for safety outcomes nor designed to determine causation of safety outcomes.

Evaluation of new-onset diabetes post-liver transplantation: A retrospective analysis of risk factors and management of hyperglycemia
K. Linder, S. Martin; Hartford Hospital, Hartford CT
OBJECTIVES: Liver transplantation is the treatment of choice in patients with end-stage liver disease. Subsequent development of impaired glucose regulation undermines the benefit of liver transplant by reducing allograft and patient survival. Despite the prevalence and unfavorable outcomes associated with hyperglycemia and new-onset diabetes after transplant (NODAT), assessment of patient risk, management of hyperglycemia post-transplant, and prevention is not well understood. The primary purpose of this study is to assess the difference in insulin burden between liver transplant patients who develop NODAT and patients who do not.

METHODS: This is a single-center, retrospective cohort study. Consecutive charts of adult (? 18 years of age) liver transplant recipients transplanted between January 1, 2005 and August 1, 2013 were included. Patients were excluded if they received a multi-organ transplant, expired within seven days of transplant, or if they had a pre-transplant diagnosis of diabetes mellitus. All patients were followed for one-year or until death, whichever happened first. NODAT was defined as one of the following: (1) use of an oral anti-hyperglycemic agent for ? 30 consecutive days after transplant, (2) use of insulin ? 30 consecutive days after transplant, or (3) HbA1C ?6.5 any time after transplant.  This study was approved by the Hartford Hospital Institutional Review Board with a waiver of informed consent.

RESULTS: A total of 154 patients were identified as having received a liver transplantation between January 1, 2005 and August 1, 2013. Twenty-eight patients had a pre-existing diagnosis of diabetes and were excluded from the analysis. An additional five patients expired within seven days of transplant and were excluded. Four patients were duplicates and three patients were excluded because of missing information. Of the 114 patients included, 48 (42%) developed NODAT. The average 24-hour insulin requirement on the medical floors was 17.2 ± 14.5 mg/dL in the NODAT group and 11.3 ± 12.2 mg/dL in the non-NODAT group; p = 0.024.  The average blood glucose level on the medical floor was 184.7 ± 31.5 mg/dL in the NODAT group and 169.3 ± 31.4 mg/dL in the non-NODAT group; p = 0.013.  Differences in intensive care unit average blood glucose and average 24-hour insulin requirement were not found to be statistically significant between the two groups. Multivariate analysis revealed that experiencing rejection was positively associated with the development of NODAT; adjusted odds ratio (AOR) 3.237 (95% CI 1.214 – 8.633).  Basiliximab was negatively associated with the development of NODAT; AOR 0.182 (95% 0.040 – 0.836).  

CONCLUSION: Liver transplant recipients are at an increased risk for developing NODAT. This analysis suggests that rejection is a positive predictor and use of basiliximab is a negative predictor for the development of NODAT. Further analyses are required to better determine appropriate strategies for the treatment of hyperglycemia and prevention of NODAT immediately post-liver transplant.