Journal of pharmacy practice最新文献

Background: The renin-angiotensin-aldosterone system (RAAS) is responsible for a multitude of physiological functions, including immunological effects such as promotion of TGF-β and upregulation of IL-6 and IL-8 which are also implicated in the development of chronic lung allograft dysfunction (CLAD). Blockade of the RAAS pathway in pre-clinical models has demonstrated a decrease in these cytokines and pulmonary neutrophil recruitment. Objective: This study sought to evaluate whether use of RAAS inhibitor (RAASi) in lung transplant recipients impacted CLAD-free survival. Methods: In this retrospective, single-center study, 35 lung transplant recipients who received a RAASi post-transplant were compared to 70 lung transplant recipients not exposed to a RAASi and were followed for up to 5 years post-transplant. Results: The incidence of CLAD did not differ based on RAASi treatment (34.3% in RAASi vs 38.6%, P-value .668). This was confirmed with a multivariable Cox proportional hazards model with RAASi initiation as a time-varying covariate (RAASi hazard ratio of 1.01, P-value .986). Incidence of hyperkalemia and acute kidney injury were low in the RAASi group. Conclusions: This study demonstrated no association between post-transplant RAASi use and decreased risk of CLAD development. RAASi were also well tolerated in this patient population.

Purpose: To report an incident of a breakthrough deep vein thrombosis (DVT) and potential example of a drug-drug interaction in a patient treated with edoxaban and rifabutin who was being treated for respiratory tuberculosis. Case: A 76-year-old male presented with anemia requiring transfusion and subsequent shortness of breath that was later diagnosed to be respiratory tuberculosis. He experienced a prolonged hospital stay due to persistently positive Mycobacterium tuberculosis respiratory samples and a complicated social situation that required continuous hospitalization for approximately five months. During his treatment the patient was transitioned from apixaban to edoxaban due to a drug-drug interaction with rifabutin. He subsequently had a DVT while on edoxaban after two months of therapy that would require him to transition to warfarin. Conclusion: This case represents an example of a potentially significant drug-drug interaction between edoxaban and rifabutin. Other direct oral anticoagulants (DOACs) exhibit a potential drug-drug interaction that limit their effectiveness when used with rifamycins. This report describes the first known case of a patient experiencing a DVT after prolonged edoxaban use in combination with rifabutin. Treatment with DOACs for patients taking concomitant cytochrome P450 (CYP) inducers such as rifabutin may be more complicated than previously believed.

Venous thromboembolism prophylaxis with subcutaneous unfractionated heparin or low molecular weight heparin is a common practice in hospitalized patients. Typically, prophylactic doses of these medications have poor bioavailability and thus do not reach therapeutic serum concentrations. However, in certain circumstances, heparin binding proteins may become saturated. Here we report a case series of 5 patients who had elevated anti-Xa levels while receiving prophylactic dosing of subcutaneous unfractionated heparin.

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: Angiotensin II (ATII) has been shown in the literature to increase the risk of thrombosis. Little data exists in patients with mechanical circulatory support (MCS) due to exclusion from landmark trials. Objective: Evaluate the thrombotic risk of ATII in patients in the cardiothoracic intensive care unit (CTICU) with distributive shock. Methods: Retrospective study including adult patients admitted to the CTICU with temporary MCS. This study evaluated patients ≥18 years old on temporary MCS in the CTICU between September 1st, 2018 and August 30th, 2022. Patients that received ATII were compared to a control group for the outcome of an index thrombotic event. The outcomes were compared using the Fischer's exact or chi-squared test. Results: A total of 75 patients primarily admitted for cardiac surgery were included, of which 41 (54.7%) received ATII. The rates of overall thrombosis were higher in the ATII group compared to the control, though the outcome was not statistically significant (41.5% vs 20.6%; P = 0.05). Individual thrombotic components of the composite outcome were not statistically significant between groups. Conclusion: Numerically higher rates of thrombosis were seen in patients on MCS that received ATII, though the outcome was not statistically significant. This retrospective study provides a single-center, real-world safety perspective on the use of ATII in MCS.

Background: The purpose of this case report is to describe a case of switching warfarin to apixaban in a patient on anticoagulant prophylaxis for a patent foramen ovale (PFO)-associated stroke. Case Summary: An 86-year-old Afro-Latina female with a past medical history of cerebrovascular accident (CVA) in 2012 secondary to PFO and diagnosed Atrial Fibrillation (AF). Patient was switched from warfarin to apixaban after 3 months of labile international normalized ratio (INR) levels. The patient's INR was monitored at a pharmacist-led anticoagulation clinic. As the patient's INR remained subtherapeutic while on warfarin, a shared decision was made to switch the patient to apixaban 2.5 mg twice daily due to consistently painful enoxaparin injections, inconsistent vitamin K intake, frequent clinic visits and unstable renal function. Patient tolerated the anticoagulant switch well and reported satisfaction with decreased clinic visits and variable vitamin K diet. At 12 months post-switch, the patient's complete blood count remains stable, no reported signs and symptoms of bleeding, and no new CVA or venous thromboembolism (VTE) events identified. Based on an improvement in renal function, the dose was increased to 5 mg twice daily.

Background: Patients maintained on extracorporeal membrane oxygenation (ECMO) often require systemic anticoagulation to prevent circuit clotting and systemic thromboembolic complications. The optimal intensity of anticoagulation to balance the risk of bleeding and prevention of thrombotic complications in this patient population is not well described. Objective: To compare bleeding events in patients on ECMO anticoagulated with standard vs low intensity heparin protocols. Methods: This single-center, retrospective cohort study included adult patients on VA- or VV-ECMO and anticoagulated with low or standard intensity heparin protocols. The primary outcome was the incidence of major bleeding; secondary outcomes included the incidence of minor bleeding, thrombotic complications, heparin-induced thrombocytopenia, in-hospital mortality, time in therapeutic range, anti-Xa correlation with aPTT, intensive care unit and hospital lengths of stay, oxygenator exchanges, and rate of protocol switching. Results: A total of 27 patients (14 low intensity, 13 standard intensity) were included. There were six major bleeding events in the low intensity group and four in the standard intensity group (P = 0.69); there were four minor bleeding events in the low intensity group and five in the standard intensity group (P = 0.69). Seven patients in the standard intensity group switched protocols; zero patients in the low intensity group switched protocols (P = 0.002). There were no differences in any other outcomes. Conclusions: There was no difference in the incidence of any bleeding or thrombotic events when using a low vs standard intensity heparin protocol in patients on ECMO. A low intensity heparin strategy for patients on ECMO may be feasible and safe.

Staphylococcus aureus is a leading cause of invasive bacterial infections in the pediatric population. In general, data surrounding the use of newly approved antimicrobials within children are lacking. Dalbavancin is a long-acting lipoglycopeptide that shows promise for off-label use in adults given its unique pharmacokinetics and in vitro potency against common Gram-positive isolates; however, evidence to supports its use in children is limited. We report the use of dalbavancin in three pediatric cases in patients aged 17 months of age, 3 years of age, and 11 years of age. All infections were caused by S. aureus (66.7% methicillin-resistant S. aureus) representing varied disease, including an osteoarticular infection and catheter-related bloodstream infection. Furthermore, all patients had pediatric infectious diseases involvement. Following the utilization of DAL, high clinical success and low rates of adverse effects were observed with high patients' and parents' satisfaction. While larger, confirmatory real-world studies are needed, our findings support safe off-label DAL use in select pediatric patients.

Purpose: To describe a case of significantly increased warfarin requirements in a patient receiving rifampin for the management of tuberculosis. Summary: A 76-year-old male was admitted due to altered mentation, cough, and weight loss. He was diagnosed concurrently with tuberculosis and a pulmonary embolism. Given the profound effect of rifampin on CYP450 enzymes, direct oral anticoagulants were avoided and warfarin therapy was selected. Management was further complicated by a gastrointestinal bleed during admission, history of cancer, and low body weight. After several weeks of daily international normalized ratio monitoring, a stable regimen of 14 mg of warfarin daily was established, allowing for the patient's safe discharge. Practice Implications: This report underscores the significance of tailored treatment plans, vigilant monitoring, and interdisciplinary collaboration which are necessary to navigate the complexities associated with these medications and optimize patient outcomes.

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.