Journal of pharmacy practice最新文献

In critically ill patients, fluid resuscitation with balanced crystalloids close to plasma osmolarity have a lower risk of electrolyte imbalances and demonstrated better clinical outcomes compared to normal saline (NS). While lactated ringer's (LR) has shown benefit over NS, plasma-lyte (PL) with a higher osmolarity and different electrolyte formulation is hypothesized to be superior. We performed a retrospective observational cohort study over 37 months at a tertiary hospital. Inclusion criteria were hospitalization in the surgical intensive care unit (SICU), trauma indication, ≥18 years old, and received either PL or LR. All PL administrations and every fifth patient with LR as resuscitation were included in order to match the sample size in each group. Primary outcomes were SICU length of stay (LOS), hospital LOS, and mortality. Secondary outcomes were biomarker changes from baseline. There were 113 patients in both PL and LR groups. The PL arm had higher APACHE II scores (16 vs 13, P = .033) and were more likely ventilated (39.3% vs 20.4%, P = .002) compared to LR. Median hospital LOS (12.0 vs 8.0, P < .001) and SICU LOS (6.0 vs 3.0, P < .001) are significantly longer in PL group compared to the LR group. However, there was no difference in in-hospital mortality (5.3% vs 3.5% P = .519) and SICU mortality (9.7% vs 5.3%, P > .208) between PL and LR. Overall, PL use was associated with prolonged hospital and SICU LOS. PL use did not demonstrate mortality benefit. However, patients were more critically ill in PL group based on higher APACHE II scores and higher rates of mechanical ventilation, which could be contributing to these unfavorable outcomes.

PurposeInfectious Diseases (ID) pharmacy expertise is crucial for the success of antimicrobial stewardship (AMS) efforts. As health systems expand due to mergers and acquisitions, ID pharmacy teams strive to deliver consistent care across the enterprise. This report describes the fusion of multiple AMS practice models during the integration of health systems to optimize and standardize care delivery.SummaryThe merger of two large, community hospital systems necessitated the recalibration of services of both legacy antimicrobial stewardship programs (ASPs). While there was agreement that ID pharmacists perform daily prospective audit and feedback of antimicrobials and respond to diagnostics and cultures, the prioritization of practices across the enterprise that retained allowances for individual hospital nuance was paramount. The result was a practice model dedicated to consistent patient care regardless of geographic location, socioeconomic status, or reliance on a single ID pharmacist's availability. Additionally, the team coordinates the system ASP, in collaboration with medical staff. This includes implementation of stewardship initiatives, formulary management and guideline and document control. Lastly, ID pharmacists serve as a resource for prescribers and pharmacy staff and leadership.ConclusionThe development of a standardized ID pharmacy practice model delivered through a hybrid of remote and in-person coverage addressed disparities in clinical services, education and ASP management. Complexities such as care gaps during leave are reconciled with this process while maintaining the minimum expectations of every ID pharmacist. This was especially crucial to establish consistent patient care across state lines with the rise of virtual services and inability to develop on-site rapport.

This report explores the potential role of glucagon-like peptide 1 (GLP-1) receptor agonists in minimizing the metabolic side effects of psychotropic medications in patients with underlying type 2 diabetes (T2D) in inpatient psychiatric settings. The introduction of novel antidiabetic medications such as GLP-1 receptor agonists has broadened the options for managing metabolic disorders, particularly T2D. These medications not only offer effective glycemic control but also provide cardiovascular and renal benefits and help with weight management. Given the tendency of psychotropic medications to cause weight gain and metabolic complications, this report presents 2 cases where weekly doses of semaglutide improved blood glucose levels and prevented weight gain in patients receiving chronic psychotropic medications. Integrating GLP-1 receptor agonists into inpatient psychiatric care can help mitigate the metabolic adverse effects of psychotropic medications. However, considerations such as cost, accessibility, and institutional formulary restrictions are essential to ensure comprehensive patient care.

Background: Vancomycin is an antibiotic known to cause nephrotoxicity, particularly when a vancomycin trough of 15 to 20 mg/L, a surrogate for an area under the curve (AUC) of at least 400 mgh/L, is targeted. Although monitoring vancomycin AUC is more resource intensive, it may especially benefit populations expected to be at higher risk of nephrotoxicity. Objective: To describe the proportion of discordance between vancomycin AUC and trough concentration in targeted high-risk populations. Methods: A prospective observational review was conducted on adults receiving intravenous vancomycin for more than 48 hours from May 9 to June 3, 2022. Patients included were elderly, obese, had renal dysfunction, and/or received 4 grams or more of vancomycin daily with a pending vancomycin trough concentration. A peak concentration was ordered by a project team member to calculate AUC to assess discordance. Results: A total of 47 patients were included with 87 vancomycin minimum concentration (Cmin)/AUC pairs analyzed. Discordance was observed in 52.9% of Cmin/AUC pairs in the entire cohort. The majority (79%) of the 43 Cmin levels <15 mg/L had an associated AUC >400 mgh/L and 57% of 21 Cmin levels within the 15 to 20 mg/L range had an AUC >600 mgh/L. Conclusion: A high degree of discordance between vancomycin Cmin and AUC was present in patients considered to be at high risk of nephrotoxicity. Monitoring vancomycin AUC in these patients may reduce the risk of nephrotoxicity.

Background: Clinicians often hesitate to adjust antihypertensive medications based solely on clinic blood pressure (BP) readings. Limitations to obtaining home readings include access to sphygmomanometers and ability to provide accurate, reliable readings upon follow-up. Objective: This study examined whether an online platform linked to remote BP monitoring improved BP management and facilitated effective clinical interventions by pharmacists. Methods: Thirty patients with uncontrolled hypertension were enrolled and provided a remote BP monitor for home use. BP data downloaded to an online platform were monitored by two clinic pharmacists. Daily BP checks were requested (up to twice daily), and pharmacists called patients approximately weekly for 6 months. Through approved protocols, pharmacists individualized interventions to improve patient care. Descriptive statistics were used for demographic and clinical data. Results: The average systolic BP reduction was 39 mmHg (IQR = 17-52.5) for the 21 patients included in analysis. A target BP <140/<90 was achieved by 67%, and 76% had improved BP control. Patients utilized the cuff 2-4 times (n = 10) or >5 times weekly (n = 11). Through 261 patient contact attempts, the pharmacists requested more BP checks (n = 62), changed medications (n = 57), or provided non-pharmacologic counseling (n = 24) most often. Medication changes commonly included dose increases (n = 35) and additional agents (n = 17) for BP control. Spironolactone (n = 5) and thiazide diuretics (n = 5) were the most added medications. Conclusions: Most patients were willing to check their BP when provided with devices. The majority achieved a clinically significant decrease in home BP readings, demonstrating that pharmacist-driven home-monitoring programs can improve the optimization of hypertension regimens.

Background: Transitions of care (TOC) are important to best practices as they are at times prone to medication errors. The intensive care unit (ICU) is an essential location needing effective TOC due to many reasons, but an important one being that certain medications are only indicated there. One example is antipsychotics used for agitation, delirium, and sedation. Objective: To design, implement, and analyze the benefit of a pharmacist intervention on inappropriate antipsychotic continuation from the ICU to another point in care at a small community hospital. Secondary outcomes include patients discharged from the hospital on antipsychotics inappropriately and accepted pharmacist interventions. Methods: This standard of care, prospective with historical control study included adult patients who were ordered a formulary antipsychotic for delirium, agitation, or sedation during their ICU-level of care admission at SSM Health: St. Clare Hospital- Fenton. Results: There were 33 patients in the historical period and 24 in the intervention period. Those in the intervention period were less likely to have a continuation of antipsychotics beyond 72 hours compared to patients in the historical period (16.7% vs 57.6%, P = 0.002). In addition, patients in the intervention period were less likely to have continuation of antipsychotics when discharged to home (12.5% vs 36.4%, P = 0.04). Conclusions: A pharmacist-driven intervention led to a significant decrease in patients continuing antipsychotics upon ICU discharge. This decrease was seen at both 72 hours from patients leaving the ICU and at hospital discharge.

Background: The 2019 Center for Disease Control and Prevention's Core Elements of Hospital Antibiotic Stewardship identifies community-acquired pneumonia (CAP) as a crucial area for improving antibiotic use. Transitions of care (TOC) pharmacists can optimize medication therapy for CAP patients. Methods: This was a retrospective, multi-hospital analysis of discharge antibiotic prescribing. Between December 1, 2022, and June 30, 2023, TOC pharmacists intervened to decrease discharge days of therapy (DOT) for CAP therapy. The study compared records of CAP patients with a TOC antibiotic stewardship intervention vs those without. An additional three-group analysis compared patients without an intervention to those with an accepted intervention to those with a rejected intervention. Results: 196 patient records were included in the analysis; 80 had a TOC pharmacist intervention and 116 did not. 62 interventions were accepted and 18 were rejected. Mean final discharge DOT was 3.8 ± 1.7 days in the non-intervention group and 3.4 ± 1.6 days in the intervention group (P = 0.231). Mean total DOT was 6.8 ± 2.3 days and 6.8 ± 1.8 days, respectively (P = 0.963). The percentage of patients with appropriate total DOT was 59.5% and 66.3%, respectively (P = 0.337). In the three-group analysis, mean final discharge DOT was 2.9 ± 1.7 days in the accepted group and 4.2 ± 0.9 days in the rejected group (P = 0.030). Mean total DOT was 6.4 ± 1.6 days and 8.1 ± 1.8 days, respectively (P = 0.009). The percentage of patients with appropriate total DOT was 82.3% and 11.1%, respectively (P < 0.001). Conclusion: The accepted TOC pharmacist interventions significantly reduced both discharge DOT and total DOT. These findings emphasize the impact TOC pharmacists can have with antimicrobial stewardship initiatives.

Objectives: Bariatric surgery, the most effective treatment for obesity and type 2 diabetes, may alter the absorption and overall bioavailability of orally administered drugs. In this case series, we present three patients undergoing one-anastomosis gastric bypass (OAGB) and their treatment with the anticonvulsant and mood stabilizer lamotrigine. Key Findings: Various mechanisms may be involved in the changes in lamotrigine blood levels following OAGB; some may lead to increased drug exposure, while others to its decrease. It was found that low and insufficient (case 1), higher (case 3), or unchanged (case 2) lamotrigine plasma levels are all possible after the surgery. Conclusion: This case series shows the complexity of drug treatment after bariatric surgery. The potentially large variability among patients in the effect of the surgery on the bioavailability of lamotrigine, a highly prescribed, life-saving medication, highlights the special care that must be taken with post-bariatric pharmacotherapy in general, and epilepsy treatment in particular.

Semaglutide is a glucagon-like-peptide-1 receptor agonist (GLP-1 RA) that is approved for the treatment of type 2 diabetes mellitus (T2DM) and obesity. Common adverse drug reactions (ADR) of semaglutide include nausea, vomiting, abdominal pain, constipation, and diarrhea, which are often dose-dependent in nature. Select ADRs that are less common, but may result in more significant concerns, include development of acute pancreatitis, gallbladder and biliary tract diseases, acute kidney injury, and ileus. Limited clinical literature exists at present regarding management of GLP-1 RA overdose, particularly for subcutaneous semaglutide. This report describes an 80-year-old male with T2DM and mild cognitive impairment who self-administered subcutaneous semaglutide 1 mg daily over the span of 7 days. The patient denied any ADRs, including those related to gastrointestinal upset or hypoglycemia. Blood glucose readings from the patient's glucometer ranged from 100 - 180 mg/dL. The patient declined to present for medical evaluation until 5 weeks after the overdose incident. No clinically significant changes were noted in his renal function, hepatic function, nor his pancreatic enzymes upon laboratory follow-up. Published reports concerning GLP-1 RA overdoses describe mixed presentation of patients following such events. Treatments detailed in the case reports included primarily supportive care measures. Based on the mechanism of action of GLP-1 RAs, and those case reports detailed, we recommend close monitoring and supportive care in the form of providing antiemetics, correcting fluid and electrolyte imbalances from gastrointestinal losses, and monitoring for hypoglycemia in the event of an overdose.