Journal of pharmacy practice最新文献

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.

Utilization of cangrelor following coronary artery stent placement as a bridge to cardiac surgery has been previously described in the literature. However, the use of cangrelor as bridge therapy to cardiac surgery for endovascular revascularization is lacking. We describe a case involving a 47-year-old female who developed a left lower extremity tibioperoneal trunk non-obstructing arterial dissection following extracorporeal membrane oxygenation decannulation, requiring repair with a Viabahn endoprosthesis. To maintain stent patency, as well as treat the patient's multi-vessel coronary disease and left ventricular thrombus, triple therapy with cangrelor, aspirin, and bivalirudin was utilized as the patient was optimized for a coronary artery bypass procedure. Our case describes a unique antiplatelet and anticoagulation strategy in a complex patient involving a multi-disciplinary team.

Purpose: A case of enoxaparin-induced bullous hemorrhagic dermatosis is reported. Summary: A 69-year-old male with past medical history including chronic atrial fibrillation and a re-do aortic valve replacement, anticoagulated on warfarin, received an enoxaparin bridge for a molar extraction. On day 7 after restarting enoxaparin post-procedure at a therapeutic dose of 90 mg every 12 hours, the patient noticed multiple small, dark, raised lesions on his forearm and ankle. The patient denied pain, itchiness, or initiation of new medications other than enoxaparin. The patient had never experienced this side effect in the past, although he had two prior exposures to enoxaparin. A review of the available literature on cutaneous side effects from enoxaparin was performed and it was determined that the patient experienced enoxaparin-induced bullous hemorrhagic dermatosis. There is currently limited guidance on management of this rare side effect and whether enoxaparin rechallenge is safe. As benefit outweighed risk for the patient, the enoxaparin bridge was continued for an additional 3 doses, until the patient completed his supply of enoxaparin at home. Approximately within 1 week after enoxaparin was discontinued, the hemorrhagic bullae disappeared. The patient was re-exposed to enoxaparin 6 months later for a colonoscopy and the side effect did not reoccur. Conclusion: It may be safe to continue enoxaparin while experiencing enoxaparin-induced bullous hemorrhagic dermatosis as the condition is typically self-limiting. This case report shows that re-exposure to enoxaparin may be safe as it may not result in reoccurrence of the side effect.

Purpose: Emergency response teams are designed to promptly deliver care to hospitalized patients experiencing acute decompensation events. Pharmacists are an integrated part of emergency response teams and their presence at emergency response events has been shown to improve adherence to institutional and advanced cardiac life support (ACLS) guidelines. This study assesses the impact of pharmacist involvement at emergency responses and time clinical pharmacists dedicate to emergency response. Methods: A single-center, retrospective chart review assessed inpatient and ambulatory emergency responses for patients 18 and older from August 2021 through January 2022. Emergency response event-specific information was assessed using intervention documentations in the hospital electronic health record (EHR). The amount of time dedicated to emergency response by pharmacists was then converted to full-time equivalents (FTE). Results: Of the 296 emergency response documentations assessed, 242 responses were included in analysis. The primary outcome of time pharmacists dedicate to emergency responses over a six-month period was found to be 9480 minutes (158 hours). The average amount of time spent at each response was 40.7 minutes (SD 27.4 minutes), ranging from 5-210 minutes. Conclusion: The total time spent by clinical pharmacists at emergency responses within a six-month period was equivalent to approximately 26% of an FTE. Due to inability of pharmacists to document all emergency responses, this may be under-represented. More than 70% of emergency responses required 6-10 medications be prepared by pharmacists. Pharmacists made interventions 47% of the time, indicating that pharmacists play an integral role as members of emergency response teams.

Background: Transitions of care (TOC) is defined as the movement of patients between healthcare practitioners, settings and home. Ineffective TOC can lead to hospital readmissions, increased costs, and patient dissatisfaction. Pharmacists have a unique opportunity to ensure that continuity of care, in regard to medication optimization and education, is continued throughout the transition between settings. With both inpatient and ambulatory pharmacists supporting smooth discharge for hospitalized patients, an opportunity was identified to implement a pharmacist-to-pharmacist TOC program at Ascension Genesys Hospital (AGH). Objective: Implement a pharmacist-to-pharmacist TOC program at AGH. Methods: This was a single-center pilot program in which a pharmacist-to-pharmacist TOC program was implemented at AGH between January 1st and April 30th, 2024. Patients were included if they were 18 years of age and older, managed by the family medicine (FM) team, and had at least 5 medications at discharge. The FM and ambulatory pharmacists provided recommendations and all medication related problems (MRPs) and interventions were documented. Descriptive analysis was conducted. Results: A total of 25 hospitalized patients and 10 follow-up patients were included. A total of 44 inpatient MRPs and 41 outpatient MRPs were recorded. The most common inpatient MRP was antibiotic stewardship. The most common clinic MRP was medication access barrier. Conclusion: Implementation of the pilot program occurred and results were reported. These results demonstrate the importance of pharmacist involvement in TOC.

Background: Traditional Post-Intensive Care Recovery Clinics (PIRCs) often exclude neurocritical care patients. In 2020, a multidisciplinary team started Post Neuro Intensive Care Virtual Clinic (PREVAIL) that uses telemedicine to provide consultative care for patients with a primary neurologic injury who are at risk for post-intensive care syndrome. During clinic, critical care pharmacists perform medication reconciliations and provide drug therapy recommendations. Objectives: The objective of this observational review is to describe the pharmacists' interventions and role in a novel PIRC. Methods: A retrospective, observational review was conducted for patients who were seen in PREVAIL from December 2020 to January 2022. The pharmacist completed a medication reconciliation and provided drug therapy recommendations. Results: Amongst fifty-two PREVAIL patients, the most common neurologic diagnosis was intracerebral hemorrhage, seizures, and acute ischemic stroke. All patients were mechanically ventilated during their ICU stay, with a median ICU length of stay of 17 days [IQR 10-26]. After medication reconciliation, 93% of patients required adjustments to their medication list. After patient examination, 89% of patients required a drug therapy recommendation, with a median of three interventions per patient. Various medication classes were intervened on, most frequently antipsychotics, anti-seizure medications, antihypertensives, anticoagulants, neuromodulators, and antidepressants. Conclusion: This is the first study to evaluate pharmacist contributions at a consultative telemedicine PIRC that focuses on providing care for patients with a primary neurologic injury. PREVAIL pharmacists have a crucial role in the multidisciplinary team. Future research is required to determine the pharmacist's impact on clinical outcomes.

Purpose: Infectious 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.

Summary: The 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.

Conclusion: The 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.