Journal of pharmacy practice最新文献

Introduction: Dicyclomine is an antimuscarinic agent approved for treatment of irritable bowel syndrome-associated abdominal pain. Intravenous (IV) administration should be avoided due to potential for thrombosis, but real-world evidence is generally lacking. This case report presents a thrombotic complication associated with inadvertent IV administration of dicyclomine. Case: A 43-year-old man with chronic colitis and recurrent Clostridioides difficile infections presented to a community hospital complaining of moderate-severe suprapubic abdominal pain and nausea/vomiting/diarrhea for 5 days. Computed tomography showed descending colonic wall thickening and proctitis, without perforation or abscess. Initial orders consisted of ketorolac 15 mg IV and dicyclomine 20 mg intramuscularly. The nurse inadvertently mixed ketorolac and dicyclomine in the same syringe and administered them simultaneously. Ultrasound subsequently confirmed a non-occlusive right axillary vein thrombosis and an occlusive superficial right basilic vein thrombosis. The patient was started on therapeutic enoxaparin subcutaneously. He was enrolled in a patient assistance program and was discharged on rivaroxaban dispensed from the hospital's outpatient pharmacy. Discussion: Dicyclomine is more selective for the M₁ and M₃ receptors, and the M₃ receptor causes nitric oxide activation. As dicyclomine was unintentionally administered IV, the inhibition of nitric oxide could potentially lead to clotting. The simultaneous administration of ketorolac promoted a pro-thrombotic state, via cyclo-oxygenase-2-mediation vasoconstriction. Naranjo algorithm assessment indicated "possible" potential for a drug-induced adverse event. The pharmacist submitted an adverse drug event report and revisions to barcode medication administration were implemented. Conclusion: Thrombotic complications are possible following IV dicyclomine administration and pharmacy personnel must implement safeguards to prevent inadvertent administration.

Objectives: The objective of the present study is to assess the association of erythromycin and clindamycin susceptibilities with 30-day mortality in patients with MSSA bacteremia treated with cefazolin. Methods: Retrospective cohort study of patients with least one positive blood culture growing MSSA and treated with cefazolin for at least 3 consecutive days. Groups included patients who had an MSSA strain that was both erythromycin and clindamycin susceptible (E/C-S), the comparator group included patients with erythromycin resistant and clindamycin resistant or susceptible (E/C-R) MSSA strains. The relative risk for 30-day mortality was calculated for E/C-R compared to E/C-S along with the sensitivity and specificity for E/C-R as a predictor of 30-day mortality. Results: A total of 114 patients were eligible for analysis; with 72 (63%) categorized in the E/C-S group and 42 (37%) categorized in the E/C-R group. The primary outcome of 30-day mortality was met in 7 (10%) patients in the E/C-S group vs 7 (17%) in the E/C-R group; unadjusted relative risk (95% CI) 1.71 (0.65-4.55). The sensitivity and specificity of E/C-R as a predictor of 30-day mortality was 50% (95% CI = 23-77) and 65% (95% CI = 55-74), respectively. Conclusions: This exploratory study did not find clindamycin or erythromycin susceptibility to be associated with 30-day mortality in patients treated with cefazolin for MSSA bacteremia. The relevance of this surrogate marker in clinical practice is negligible due to its limitations, and future investigations are required to establish pragmatic means of detecting isolates which may be insufficiently treated with cefazolin.

Background: Sleep disruption and delirium are common among children requiring intensive care. Melatonin secretion is altered in critical illness and supplementation may be beneficial. Objective: To characterize melatonin use among children admitted to a pediatric intensive care unit (PICU) within a large pediatric healthcare organization and explore associations with delirium screening scores. Patients and Methods: This was a retrospective, observational study of children (1 month-18 years) admitted to 2 PICUs between January 1, 2021, and January 1, 2023. Results: A total of 642 admissions (556 patients; age = 8.8 ± 5.6 yr.) were included and represented approximately 8% of total PICU admissions during the study period. The mean melatonin dose was 3 ± 2.43 mg. Sixty percent of admits started melatonin within 48 hours of PICU admission. Eighty-three percent continued melatonin after transfer to the floor. An association between melatonin and a reduction in the percent of delirium scores ≥9 was observed in patients receiving melatonin for presumed delirium, with a more robust reduction detected in those receiving at least 7 days of melatonin therapy. Twenty-five percent of admits not on melatonin prior to admission were discharged with a new melatonin prescription. Conclusions: Melatonin, when prescribed in the PICU is typically started within 48 hours of admission at a dose of 3 mg. A reduction in the burden of positive delirium scores was observed after starting melatonin in children using melatonin for presumed delirium. Continuation of therapy after ICU transfer and discharge to home is common.

Background: Health-system clinical pharmacists are responsible for a wide range of tasks throughout the workday. Recent literature highlights the prevalence of burnout among pharmacists and the challenges they face in finding adequate time to complete non-patient care responsibilities. Objective: The objective of this study was to describe the administrative time practices of health-system clinical pharmacists around the United States. Methods: This study involved a survey distributed via e-mail to members of the American College of Clinical Pharmacists Practice Research Networks and American Society for Health-Systems Pharmacists online forums in March 2023. The survey contained 18 items aimed at describing pharmacist administrative time practices. The primary endpoint was the number of pharmacists reporting dedicated, protected administrative time availability. Results: A total of 303 pharmacists responded to the survey. Most were clinical specialists (n = 163, 53.8%) who had been practicing for more than 10 years (n = 132, 43.6%) in an academic medical center (n = 138, 45.5%). In regards to the primary endpoint, the majority (n = 198, 65.3%) responded that they are not provided dedicated, protected administrative time. When residency program directors (RPDs) (n = 57) were asked if they were specifically allotted administrative time, a majority of RPDs (n = 32, 56%) responded no. Conclusion: The majority of responding health-system clinical pharmacists are not provided with protected administrative time to complete non-patient care related tasks. Administrative time is one modifiable factor from the institutional perspective that can help to mitigate pharmacist burnout.

BackgroundThe 2020 consensus guidelines for drug monitoring of vancomycin recommended AUC-guided dosing to reduce acute kidney injury (AKI) and improve clinical outcomes in patients with serious methicillin-resistant Staphylococcus aureus (MRSA) infections previously managed with trough concentrations of 15-20 mg/L.ObjectivesTo determine if AUC-guided dosing of vancomycin reduces AKI and improves clinical outcomes including non-invasive infections with S. aureus compared with trough-only dosing broadened to concentrations of 10-20 mg/L.MethodsA retrospective, single-center, cohort study was conducted over 12 months comparing Bayesian software-guided AUC-dosing with trough-only dosing. Information collected included patient demographics, co-morbidities, concurrent nephrotoxins, assessment measures of drug exposure, and patient outcomes. Nominal data were analyzed using the chi-square test, and continuous data using the independent t test.ResultsBased on the Kidney Disease Improving Global Outcomes (KDIGO) criteria, the incidence of AKI was 7.65% and 6.06% (P = 0.56), among 183 patients in the AUC-guided and 165 subjects in the trough-only groups, respectively. Individuals in the trough-only group were younger, had fewer co-morbidities and admissions to the ICU. A lower incidence of AKI findings among trough-only subjects was likely a result of the duration of therapy (mean of 4.2 days), mean trough concentrations <15 mg/L, and fewer concurrent nephrotoxins. AUC-guided dosing significantly reduced the total daily dose, 2.29 vs 2.54 g/day (P = 0.01), but provided no significant reductions in cumulative dose, duration of therapy, length of hospital stays, or overall patient outcomes.ConclusionAUC-guided vancomycin dosing did not reduce the incidence of AKI nor impact patient outcomes vs trough-only dosing. Successful clinical outcomes with lower average trough concentrations may have resulted from the treatment of nonbacteremic skin soft tissue infections (SSTI), suggesting an indication for further exploration of vancomycin dosing strategies.

Introduction: Inclusion of numeric, actionable renal dosing recommendations in drug information resources enhances the safe use of nephrotoxins. Purpose: The purpose of this study was to systematically and descriptively characterize the renal dose recommendations for nephrotoxic medications in 4 common drug information resources. Methods: A list of nephrotoxins (N = 154) was generated from previously published lists. Renal dosing information was collected for each drug from the package insert, Lexi-comp (now called UpToDate Lexidrug), Micromedex, and Clinical Pharmacology. Dosing recommendations were categorized using a previously published 6-category scale based on whether recommendations were included vs missing, and numeric vs non-numeric. Results: Actionable renal impairment recommendations (numeric, non-numeric, contraindicated, no dose adjustment required) in the package insert, Lexi-comp, Micromedex, and Clinical Pharmacology were present for 88.3%, 98.1%, 94.2%, and 98.1% of drugs, respectively. Numeric recommendations were available for 54.5% to 75.3% of medications, depending on the source. Actionable recommendations for hemodialysis, peritoneal dialysis, continuous renal replacement, and hybrid dialysis modalities were more common in Lexi-comp (83.1%, 75.3%, 62.3%, and 53.9% of medications, respectively) vs the other resources. Actionable pediatric renal impairment (76.0%) and older adult (95.5%) recommendations were also more common in Lexi-comp than other resources. Conclusions: Drug information resources included actionable renal dosing recommendations for most known nephrotoxins, with Lexi-comp being most likely to include this information. Numeric and/or actionable recommendations for specific dosing populations (eg, renal replacement modalities, pediatric renal impairment, older adults) were generally lacking. Lack of agreement among resources suggests a need to check multiple sources in practice.

Priapism is a urologic emergency that is defined as a prolonged erection in the absence of sexual stimulation. Ischemic priapism is the most common form and is characterized by low arterial blood flow and absent venous outflow. Some potential triggers of ischemic priapism include malignancy, sickle cell disease, illicit drug use, and certain medications. Prazosin, an alpha-1 adrenergic antagonist, is used for the treatment of chronic hypertension, benign prostate hyperplasia, and (post-traumatic stress disorder (PTSD) related nightmares. The alpha-adrenergic antagonistic effect of prazosin results in decreased venous blood flow, including to the smooth muscle tissue located within the corpus cavernosum. Slowly titrating prazosin allows the body to adapt to the vasodilatory effects of the medication. Without titration, a dysregulation in blood flow to the penile vasculature can result in prolonged erection. We report a case of priapism that resulted due to rapid titration of prazosin.

Objective: The development of continuous glucose monitoring (CGM) has allowed for improved glycemic control among patients with diabetes. Clinical pharmacists possess medication expertise and can provide support for increased CGM utilization through device education and affordability assistance, but there is limited evidence evaluating the effectiveness of clinical pharmacist-assisted CGM initiation. The objective of this study was to examine how clinical pharmacist-assisted CGM implementation can impact glycemic control for patients with diabetes. Methods: This is a retrospective pre-post study that evaluated change in A1c among patients who were assisted with CGM device implementation by a clinical pharmacist between January 1, 2019, and December 31, 2023. The primary outcome of this study was change in A1c from baseline (prior to CGM initiation) to the next subsequent A1c following CGM initiation. The study team also investigated change in A1c among a subgroup of patients followed independently by clinical pharmacists practicing under a collaborative drug therapy management (CDTM) agreement. Results: Pharmacist-assisted CGM initiation led to a statically significant decrease in mean A1c of -0.71 (CI 95% 0.41-1.00, P < 0.001) across all patients. Within the CDTM subgroup, the mean A1c difference was -1.60 (CI 95% 0.64-2.55, P = 0.002) while in the non-CDTM subgroup, the mean A1c difference was -0.50 (CI 95% 0.22-0.78, P < 0.001). Conclusions: Clinical pharmacists are effective at helping patients with diabetes reduce their A1c through assisting with CGM initiation, education, and follow-up. Among patients included in this study, those followed by pharmacists practicing under CDTM agreements saw the greatest amount of A1c reduction.

Purpose: Methylene blue was FDA-approved for the treatment of acquired methemoglobinemia. However, it has also shown benefits in other disease states such as β-blocker and calcium channel blocker overdoses, vasoplegia, and ifosfamide-induced encephalopathy. More recently, methylene blue has emerged as a potential catecholamine sparing agent for the treatment of septic shock through inhibition of the nitric oxide pathway, which is responsible for vasodilation. Studies suggest that methylene blue decreases vasopressor requirements for critically ill patients with minimal safety risks. This clinical review aims to review the pharmacology, efficacy, and safety surrounding methylene blue use in patients with septic shock. Summary: Six studies conducted between 2000 and 2024 were identified. In randomized studies, methylene blue appears to be safe and effective in improving hemodynamics in patients with septic shock. This review discusses pharmacology, pharmacotherapy, and primary literature surrounding methylene blue in septic shock. Conclusion: Based on review of the available literature, authors conclude that methylene blue is an appropriate catecholamine-sparing treatment option for patients with septic shock. However, drug-drug interactions should be carefully reviewed before administration due to the risk of serotonin syndrome when combined with other serotonergic agents.

Background: Risk of acute pancreatitis is possible with several weight management medications including glucagon like peptide-1 receptor agonists. Acute pancreatitis has not been reported with the phentermine/topiramate combination product used as an appetite suppressant for chronic weight management. Summary: A 71-year-old male initiated phentermine/topiramate extended-release capsules for assistance with weight loss. Approximately 4 days after initiation, he presented to the emergency department with sudden mid-epigastric pain, nausea, and vomiting. He was subsequently diagnosed with acute pancreatitis, which was confirmed with imaging. Contributory factors for development of acute pancreatitis were ruled out including gallstones, alcohol intake, and hypertriglyceridemia. The phentermine/topiramate product was discontinued. Symptoms improved within 2 days, and his lipase was within normal limits at discharge. The Naranjo adverse drug reaction score was used to assess causality with a total score of 6, suggesting a probable cause for this adverse drug event. Conclusion: This report describes the presentation of acute pancreatitis shortly after initiation of phentermine/topiramate extended-release capsules for assistance with weight loss. Pancreatitis has not been previously reported with this combination product to the author's knowledge and impacts future prescribing for alternative agents.