Journal of pharmacy practice最新文献

Objectives: Sodium-glucose transporter-2 inhibitors (SGLT2i) are commonly used for the treatment of Type 2 Diabetes Mellitus, offering additional benefits in non-diabetic patients with conditions such as chronic kidney disease and heart failure. However, SGLT2i have been associated with an increased risk of euglycemic diabetic ketoacidosis (DKA). This case series describes three cases of patients who developed euglycemic DKA while taking SGLT2i. Key Findings: Each of the three patients with euglycemic DKA were taking SGLT2i for the treatment of diabetes and all had additional risk factors for the development of DKA. These factors included reduced oral intake, major acute illness, chronic pancreatitis, and a history of previous DKA episodes. Unfortunately, the absence of hallmark symptoms like hyperglycemia, polyuria, and polydipsia led to delayed diagnosis of euglycemic DKA in two of the three patients. Conclusion: Early recognition of risk factors and a high level of suspicion are critical in identifying euglycemic DKA in patients taking SGLT2i. Healthcare providers should conduct thorough medication reconciliation upon admission and closely monitor patients for concurrent issues, especially in cases of minimal oral intake, acute illnesses, and chronic pancreatitis. Prompt diagnosis and management of euglycemic DKA can significantly improve patient outcomes.

Background: Phenytoin (PHT) has been approved for the treatment of epilepsy. It belongs to the category of medications with a limited therapeutic window and requires therapeutic drug monitoring (TDM). PTH has been observed to induce a variety of Adverse drug reactions (ADRs) including ataxia, dystonia, nystagmus, dyskinesia, etc. Phenytoin-induced ataxia is an uncommonly observed ADR of Phenytoin whose reports are extremely limited. Case: Herein, we present a case report of a 16-year-old Asian patient with a past history of epilepsy that was admitted to a tertiary care hospital due to the development of ataxia, giddiness, and vomiting when taking Phenytoin in addition to Oxcarbazepine, Clobazam, and Levetiracetam to treat seizures. On admission, Magnetic resonance imaging (MRI) findings revealed bilateral variable cerebrospinal fluid (CSF) lesions in the parieto-occipital region of the periventricular area (periventricular leukomalacia). Additionally, serum Phenytoin levels were observed to be in the toxic range (40 μg/mL) due to which physicians confirmed the ADR to be due to Phenytoin toxicity. Thus, the Phenytoin drug was discontinued in the patient gradually and he was continued on clobazam, oxcarbazepine, and brivaracetam which led to reversal of the ADR in the patient. Conclusion: In this case, ataxia resulted from Phenytoin overdose, as confirmed by MRI and serum tests suggesting that TDM of Phenytoin is essential to prevent ADRs. Given the scarcity of ataxia cases caused by Phenytoin, awareness is lacking within the scientific community. Our aim is to provide insights to promote better monitoring and patient-centered treatment outcomes for epileptic patients.

Background: Critically ill children are vulnerable to acute kidney injury (AKI) and are often exposed to nephrotoxic medications. Objectives: We aimed to investigate the association between nephrotoxic medications and the risk of AKI in critically ill children admitted to our paediatric intensive care unit (PICU). Methods: Patients aged > 1 month to ≤18 years old were prospectively recruited from 6/2020 to 6/2021. The medication records from 14 days prior to PICU admission to PICU discharge were reviewed. Medication-exposure intensity was defined as the number of concomitant nephrotoxic medications. The relative risk (RR) of nephrotoxic medication exposure indices and other potential predictors for AKI development were determined. Results: Altogether 253 episodes of admissions (median [IQR] age of 4.9 [9.6] years) were enrolled. The AKI incidence was 41.9% and 69.2% of the patients were exposed to ≥1 of the 47 nephrotoxic medications. The total nephrotoxic medication dose (RR: 1.01 [1.00, 1.02]) and medication-exposure intensity (RR: 1.381 [1.101, 1.732]) were significantly associated with AKI development. The risk of AKI increased when the medication-exposure intensity was ≥4 (RR: 3.687 (1.320, 10.301)). During their PICU stay, children with AKI received a higher number (P < .01), total dose (P < .01) and medication exposure intensity (P < .01) of nephrotoxic medications. Children with AKI who received nephrotoxic medications were more likely to have a persistently higher peak-to-baseline ratio (P = .046). Conclusion: Nephrotoxic medication exposure significantly increased the risk of AKI development among critically ill children. The use of nephrotoxic medications among critically ill children at risk for AKI should be monitored frequently.

Background: Cefepime is used for the treatment of nosocomial infections and serves as a carbapenem-sparing agent for treating AmpC inducible bacteria. Cefepime induced neurotoxicity (CIN) is a well-documented adverse effect, although data describing the risk of CIN in patients with a history of seizures (HOS) remains limited. Objectives: The primary and secondary objectives were to compare the rates of CIN in patients with and without HOS and identify risk factors associated with CIN, respectively. Methods: This was a retrospective matched cohort study of patients admitted to University Hospital from January 2019 to December 2022 that were initiated on cefepime with and without a baseline HOS. Patients were matched at a rate of 1:1 by age (+/- 5 years), sex, and month of admission (+/- 1 month). Results: A total of 150 patients were included, 75 in each group. There was no statistically significant difference in CIN between the two groups (9 vs 7, P = 0.7923). The only risk factors associated with CIN were age >65 (OR, 5.8 [95% CI, 1.194-27.996]), acute kidney injury (AKI) during cefepime administration (OR, 13.8 [95% CI, 2.528-75.206]), and an intensive care unit (ICU) stay (OR, 8.6 [95% CI, 1.735-42.624]). Conclusion: There was no increased risk of CIN observed in patients with HOS. Patients age >65, AKI while receiving cefepime and those admitted to the ICU were 5.8, 13.8, and 8.6 times more likely to experience CIN. These results suggest that it may be safe to administer cefepime to patients with HOS in the appropriate clinical setting.

Introduction: Aminoglycosides possess activity against aerobic gram-negative organisms and are often used in combination with beta-lactam antibiotics. Previous studies evaluating combination therapy in gram-negative bacteremia have not shown clear benefits, however antimicrobial resistance was not prevalent in these studies. Our objective is to elucidate potential benefits of adding a single dose of an aminoglycoside to a beta-lactam in patients with gram-negative bacteremia. Methods: This study was a single-center, retrospective, cohort study including patients 18 years old or older and treated for at least 24 hours for a confirmed gram-negative bacteremia. Patients were divided into two groups: receipt of beta-lactam monotherapy (n = 164) and receipt of a beta-lactam in addition to a single dose of an aminoglycoside (n = 79) within 24 hours of bacteremia onset. The primary endpoint was infection-related 30-day mortality per provider documentation. Key secondary outcomes include incidence of acute kidney injury (AKI) and time to improvement of AKI. Data were analyzed using Chi-square or Fisher's exact tests, student's T test, and descriptive statistics as appropriate. Results: The primary outcome occurred in 13/164 vs 2/79 patients in the monotherapy and combination groups (P = 0.10). Incidence of AKI (14% vs. 12%) and time to recovery from AKI (90 hours; IQR [50 - 133] vs 78 hours; IQR [42 - 128]) were comparable between groups (P = 1.00 and P = 0.73, respectively). Conclusions: The addition of a single-dose aminoglycoside was not significantly associated with reduced mortality or increased time to recovery from AKI in our patient population. Larger studies, particularly in more severely ill patient populations, are needed.

Background: The increasing aging population in Australia has created a higher demand for specialist geriatric services within hospitals. A Geriatric Evaluation and Management in the Home (GEMITH) service was implemented at a quaternary Queensland hospital. The GEMITH service was unique as it incorporated a specialist pharmacist into the multidisciplinary team. Objective: To determine the medication safety and quality impact of the GEMITH service by evaluating the type and clinical significance of specialist pharmacist interventions. Methods: This was retrospective observational study of clinical interventions made by the GEMITH pharmacist for patients admitted to the service between October 2020 to April 2021. All pharmacist interventions were rated for their clinical significance using the Society of Hospital Pharmacists of Australia (SHPA) risk classification system. The ratings were undertaken by a panel of three pharmacists that independently assessed the interventions, coming together for final discussion. A narrative analysis of the interventions were derived through group consensus. Results: There was a total of 119 admissions to the GEMITH service, with 132 clinical interventions made by the specialist geriatric pharmacist. The majority (47%) of interventions were considered as low risk interventions, although high- (21%) and extreme-risk (2%) interventions still occurred. The most common type of intervention (32%) involved medication reconciliation. Other intervention types included monitoring recommendations, dosing interventions, and deprescribing suggestions. Conclusion: Multiple clinical interventions were made by the GEMITH pharmacist, which prevented possible and significant medication-related harm. This demonstrated the quality impact of the specialist pharmacist in improving medication safety for geriatric patients.

Introduction: Clopidogrel hyperresponsiveness is a timely topic, with wide ranging reports of hemorrhagic complications, using various clopidogrel dosing strategies following neuroendovascular procedures. This study serves to investigate hemorrhagic complications using standard clopidogrel doses and timing of these complications in relation to the procedure. Materials and Methods: Retrospective cohort of consecutive adult patients undergoing flow diversion with Pipeline Embolization Device (PED) at an academic medical center, receiving on-label clopidogrel doses. Patients with clopidogrel hyperresponsiveness (VerifyNow^TM P2Y12 reaction unit (PRU) ≤ 70) were compared to those who were normoresponsive. The primary outcome is the rate of hemorrhagic complications between groups. Results: Of 148 included patients, 54 (36.5%) were identified as clopidogrel hyperresponsive (PRU ≤ 70) and 94 (63.5%) as clopidogrel normoresponsive (PRU 71 - 194). There were no hemorrhagic complications observed in patients who were clopidogrel hyperresponsive, with 5 occurring in patients who were normoresponsive (P = 0.09). Three (60%) of the hemorrhages were intracranial with most occurring intra-procedure or within the first week of the procedure. Age > 60 years was the only candidate predictor for hemorrhagic complications (P = 0.004). Conclusion: Our findings are contradictory, with lower hemorrhagic complications in clopidogrel hyperresponders than prior literature, and most occurring intra-op or in the immediate acute post-op phase.

Background: Ceftriaxone is a third-generation cephalosporin commonly used for treating bacteremia caused by gram-positive organisms such as Streptococcus spp. and gram-negative organisms such as Enterobacterales. The typical doses for treating bacteremia are either 1 gram or 2 grams daily. Despite its widespread use, there are limited data on the optimal treatment dose for bacteremia. Methods: This IRB-approved retrospective cohort study evaluated the difference in the clinical failure rate among patients who received 1 gram or 2 grams of ceftriaxone once daily for documented bacteremia. Clinical failure was defined as a composite of the following: antibiotic escalation, escalation to intensive care, and 30-day readmission due to an infectious cause. Adult patients admitted to Long Island Jewish (LIJ) Valley Stream, LIJ Forest Hills, or LIJ Medical Center in 2022 who received ceftriaxone were reviewed for inclusion. Patients were excluded if they received ceftriaxone for endocarditis or meningitis, had a positive blood culture with a ceftriaxone-resistant pathogen, or received ceftriaxone for less than 72 hours. Results: A total of 128 patients were included in this study. Approximately 46.9% of the participants received a 1 gram dose, while 53.2% received a 2 gram dose. 35.4% of patients in the 2 gram group experienced clinical failure compared to 21.7% in the 1 gram group (P = .08, OR 0.51; 95% CI 0.23-1.11). Conclusion: Our findings indicate that the primary outcome of clinical failure did not significantly differ between the 1 gram and 2 gram doses.

Background: Venous thromboembolism (VTE) treatment with apixaban uses a higher 10 mg twice daily regimen for 7 days (lead-in therapy). But, in patients with initial parenteral anticoagulation treatment or those with higher bleeding risk, clinicians may not always adhere to the full 7-day lead-in duration. Methods: This retrospective cohort study included adult patients admitted to the Veterans Affairs Health care System from January 2011 to April 2022, who received at least 24 hours of parenteral anticoagulation followed by lead-in apixaban therapy for VTE. The primary outcome evaluated bleeding among patients treated with shortened lead-in apixaban (study group) compared to the standard 7-day duration (control group). Results: Seventy-eight patients were included in the control and 65 in the study group. Most patients were treated for PE (72%) and received initial treatment with enoxaparin (71%). Duration of parenteral anticoagulation was longer in the study group (3.6 days ± 3.2 vs 2.5 days ± 1.9; P < .01), and length of apixaban lead-in therapy was decreased (4.1 days ± 2.2 vs 7 days; P < .01). The primary outcome of bleeding was higher in the study group (18.5% vs 5.1%; P = .02), with no difference in VTE recurrence. P2Y₁₂ and P-gp inhibitor use, and increased creatinine and age were predictors of bleeding. Conclusion and Relevance: Bleeding events were increased in the study group, and patients with bleeding risk factors may not benefit from apixaban 10 mg twice daily. Larger studies are needed where apixaban lead-in therapy is omitted following parenteral anticoagulation in patients with bleeding risk factors.

The objective of this systematic review was to characterize the literature regarding the risk factors associated with the development of toxic shock syndrome (TSS) secondary to the use of intrauterine contraceptives (IUCs), as well as patient outcomes. A literature search was conducted spanning origin through December 12, 2022, using Embase and MEDLINE ALL. Primary literature that discussed development of TSS along with the presence of an IUC were included. Extracted data included study and participant demographics, IUC data, and infection data. Reports were evaluated for risk-of-bias using the Joanna Briggs Institute critical appraisal tool for case reports. Thirteen reports met the eligibility criteria, all of which were case reports involving one patient per case who developed TSS following the insertion of an IUC or in the presence of an IUC. The patients included in the review were women aged 23 to 50 years old. Major outcomes reported included time of IUD insertion, bacteria cultured, and antibiotic therapies administered. A minority of the reports (n = 5) provided data related to recent or prior childbirth, miscarriages, or abortions, some of which were proposed to have contributed to development of TSS. Risk-of-bias assessments identified potential concerns in four domains. This systematic review characterized literature pertaining to IUC use and TSS. There may be a low but possible risk of TSS when using an IUC; generalizability is limited given the low quality of available studies. This study was neither registered nor funded.