Journal of pharmacy practice最新文献

Purpose: Multidrug-resistant organisms (MDROs) are associated with an increased length of stay and a higher risk of mortality in hospitalized patients. A lack of literature exists that evaluates the need to empirically cover patients for historic MDROs upon readmission. Methods: A retrospective, single-center, cohort study was conducted to evaluate the impact of empiric MDRO antibiotic coverage in patients with a history of MDROs. Differences in length of stay were assessed between two groups of patients: those empirically treated for their historic MDRO and those not. Secondary outcomes included in-hospital mortality, ICU length of stay, need for antibiotic escalation, need for antibiotic de-escalation, and antibiotic duration. Results: Seventy-two patients with historic MDRO(s) were readmitted to the hospital and met inclusion criteria for this study. Hospital length of stay was similar between those empirically covered and those not (11 days vs 15.1 days; P = 0.149). When analyzed in a population only including Gram-negative MDROs, hospital length of stay was shorter in those who received empiric coverage (10.7 days vs 17.2 days; P = 0.032). Conclusion: In the total study population, empiric coverage of historic MDROs failed to significantly reduce hospital length of stay. When analyzed in a population of only Gram-negative MDROs, empiric coverage of historic organisms reduced hospital length of stay by 6.5 days. This suggests that in patients readmitted to the ICU for sepsis, empiric coverage of historic Gram-negative MDROs may be beneficial.

Objective: This review aims to emphasize the role of pharmacists for optimization of evidence-based outcomes of finerenone in multidisciplinary kidney care teams during the early detection process of CKD patients. Data Sources: A PubMed literature search was performed using keywords pharmacists, chronic kidney disease (CKD), type 2 diabetes (T2D), and finerenone. Study Selection and Data Extraction: All English-language studies on the role of pharmacists in managing CKD patients or finerenone prescriptions were evaluated. Data Synthesis: CKD is a major health problem affecting millions worldwide, especially those with T2D. In recent years, new drugs have been added to the treatment options for patients with T2D and CKD, which have been shown to reduce the risk of cardiovascular and renal complications in large clinical trials. Conclusions: Pharmacists can help detect and treat CKD in patients with T2D. They may use indicators to identify potential candidates for appropriate finerenone therapy, such as stage of CKD, albuminuria level, serum potassium concentration, and use of RAAS inhibitors. Pharmacists can provide education on the benefits and usage of finerenone, monitor response to therapy, adjust the medications and doses, prevent drug interactions, help with adherence and tolerability issues, and coordinate with other healthcare providers.

The promising results seen in the treatment of refractory hematologic malignancies with tisagenlecleucel (Kymriah), the pioneering Chimeric Antigen Receptor (CAR) T-cell immunotherapy, has stimulated a fast growth in research and clinical testing of novel CAR-T constructs, targets, and various generations of CAR T-cells. Pharmacists may receive inquiries about active clinical trials or may be contributing to the care of patients participating in these studies. This briefing discusses the on-going clinical trials that explore novel CAR T-cell immunotherapies in pediatric refractory malignancies of hematologic and solid organ origins. It can be valuable in assisting practitioners in navigating the rapidly evolving field of CAR T-cell immunotherapies.

Background: Several studies have examined INR fluctuations using pharmacokinetic (PK) models or post-hoc INR values after completing nirmatrelvir/ritonavir, but further study of the effects of the drug interaction with warfarin during treatment is necessary. Case Summary: Nirmatrelvir/ritonavir is largely utilized in the outpatient setting so data regarding INR trends in hospitalized patients on warfarin is limited. However, many who receive nirmatrelvir/ritonavir outpatient experience difficulty with presenting to clinic for INR checks due to feeling acutely ill along with isolation precautions. We present the case of a patient receiving warfarin and utilizing home INR testing for monitoring. After diagnosis of coronavirus disease of 2019 (COVID-19), she was started on nirmatrelvir/ritonavir on day five after testing positive. Most recent INR prior to the start of therapy was 2.7 and had been stable on the same dose for months prior to infection. On day two of nirmatrelvir/ritonavir, her INR rose to 4.0 on home point of care INR testing. Despite reducing her dose of warfarin by 15%, her INR remained supratherapeutic the day after completing nirmatrelvir/ritonavir (4.0) and for several checks after. One month after completion of therapy, her INR returned to therapeutic levels. Practice Implications: While PK models and case series have hypothesized both potential increases or decreases in INR with the nirmatrelvir/ritonavir and warfarin interaction, COVID-19 infection itself can cause several pharmacodynamic changes which can increase INR, including decreased appetite and, in severe cases, organ dysfunction. This case provides real-world insight into the drug interaction between nirmatrelvir/ritonavir and the drug-disease state interaction between warfarin and COVID-19.

Background: Glucagon-like peptide 1 receptor agonists (GLP-1 RAs) help manage type 2 diabetes (T2DM) and may have efficacy in steatotic liver disease. Objective: To determine the prevalence and clinical impact of GLP-1 RA use in patients with T2DM and liver disease. Methods: This was a retrospective study of adult patients with T2DM and nonalcoholic fatty liver disease (NAFLD), nonalcoholic fatty liver (NAFL), or nonalcoholic steatohepatitis (NASH) between 1/1/21-12/31/21. Patients with hepatitis B or C, or on pioglitazone were excluded. Eligible patients treated with a GLP-1 RA were compared to controls. The primary outcome was change in Fibrosis-4 (FIB-4) score, with NAFLD Fibrosis Score (NFS) as a secondary outcome. Follow-up scores were calculated from labs within 3 to 15 months after baseline. Results: Of 242 eligible patients, 79 patients (32.6%) were treated with a GLP-1 RA. At baseline, FIB-4 score was lower and NFS was higher in the GLP-1 RA group vs controls (1.80 vs 2.33; P = .101, .36 vs -.47, P < .001; respectively). At follow up, FIB-4 score decreased to 1.77 in the GLP-1 RA group and increased to 2.71 in controls (P = .045). Follow up NFS was stable in the GLP-1 RA group and increased in the control group (.36 vs -.43; P = .308). Conclusion: Patients treated with GLP-1 RAs had less evidence of liver fibrosis progression compared to no treatment, although the differences were small. These results suggest that treatment with GLP-1 RAs may have clinical impact on slowing liver fibrosis, however results should be confirmed in a larger, more diverse sample.

Background: Opioid overdoses decrease when communities have access to naloxone. Clinicians play a key role in offering naloxone to high-risk chronic opioid patients. Managed care pharmacists within our health plan noted disproportionate processing for claims of opioid utilizers compared to claims of naloxone prescriptions. Objective: To increase naloxone access and prescribing to members who classify at a dosage with a higher risk for opioid overdose, defined as over 90 morphine milligram equivalents (MME). Methods: Multiple system-wide initiatives were implemented to improve naloxone access. A claims file was pulled monthly to identify members on opioids meeting MME criteria >90 MME per day excluding members with cancer, sickle cell disease, or on hospice. A separate report was then matched to naloxone claims and prescribing percentages calculated. Results: 12 444 utilizing members on opioids were identified from June 2019 prescription claims data. Of these, 131 were on opioids exceeding 90 MME per day, or 1.05% of utilizers, and the percentage of members exceeding 90 MME per day prescribed naloxone was 6.87%. By May 2023, the percentage of opioid utilizers exceeding 90 MME per day decreased to 0.58%. Naloxone prescribing increased to 41.18%. Conclusion: A multi-pronged approach to improve access to naloxone and continued educational efforts by our health plan increased naloxone prescribing in members on opioids exceeding 90 MME per day.

Objectives: Tacrolimus remains the mainstay of immunosuppression in kidney transplantation. Understanding the relationship between therapeutic tacrolimus levels and outcomes of acute rejection, patient/graft survival, and tolerability are important. The relationship between time to therapeutic tacrolimus levels and outcomes has not been well established, specifically with the use of extended release tacrolimus formulation (LCP-Tac). This study investigated time to therapeutic tacrolimus levels of 2 tacrolimus formulations, LCP-Tac and immediate release tacrolimus (IR-Tac), as a predictor of clinical outcomes. Methods: This was a single-center, retrospective, cohort study of kidney transplant recipients at Duke Hospital between 2013-2021. The primary objective evaluated the difference in time to therapeutic tacrolimus levels with LCP-Tac vs IR-Tac regimens. Secondary endpoints included time within therapeutic range during the first 3 months post-transplant, incidence of biopsy-proven rejection, development of de novo donor specific antibodies, and patient and allograft survival at 12 months post-transplant. Results: 128 patients were included (63 in LCP-Tac group and 65 in IR-Tac group). The time to therapeutic tacrolimus level was similar between formulations (7.2 days with LCP-Tac compared to 6.7 days with IR-Tac, P = .63). The time within therapeutic range during the first 3 months post-transplant, via modified Rosendaal, was similar with LCP-Tac and IR-Tac (56.1% vs 64.8%, respectively). Rates of biopsy-proven acute rejection at 12 months were similar (7/63 (11.1%) compared to 4/65 (6.2%)). There was no difference in patient/graft survival between groups. Conclusions: The time to therapeutic tacrolimus levels did not differ based on tacrolimus formulation and was not correlated with clinical outcomes.

Clostridioides difficile is a toxin-producing bacteria that is a main cause of antibiotic-associated diarrhea. Clostridioides difficile infections (CDI) are associated with disruptions within the gastrointestinal (GI) microbiota which can be further exacerbated by CDI-targeted antibiotic treatment thereby causing recurrent CDI (rCDI) and compounding the burden placed on patients and the healthcare system. Treatment of rCDI consists of antibiotics which can be paired with preventative therapeutics, such as bezlotoxumab or fecal microbiota transplants (FMTs), if sustained clinical response is not obtained. Newer preventative strategies have been recently approved to assist in restoring balance within the GI system with the goal of preventing recurrent infections.

Background: Thrombocytopenia is due to multifactorial causes in critically ill patients. One etiology is continuous renal replacement therapy (CRRT); however, it is unknown if different modalities impact the incidence. Objectives: To compare the incidence of thrombocytopenia with the NxStage CRRT system using continuous venovenous hemodialysis (CVVHD) compared to the Prismaflex system using continuous venovenous hemodiafiltration (CVVHDF). Methods: This was a retrospective cohort study at a large academic medical center in the United States. Individuals aged 18 or older admitted to the cardiovascular ICU between June 1, 2016 and September 30, 2022, and received CRRT for at least 48 hours were identified. Results: One hundred and forty-seven patients met inclusion criteria. Sixty-one patients received CVVHD with the NxStage system, while 86 received CVVHDF with the Prismaflex system. Thrombocytopenia occurred in 57.4% of patients treated with NxStage vs 19.8% treated with Prismaflex (OR 5.46; 95% confidence interval [CI], 2.62-11.39). These results were consistent in an adjusted model (OR 5.57; 95% CI, 2.34-13.28). There was no difference in the time to thrombocytopenia between groups. Patients treated with the NxStage system had lower platelet nadirs, more heparin-induced thrombocytopenia testing, more direct thrombin inhibitor use, and more blood transfusions. Conclusions: A greater incidence of thrombocytopenia occurred in cardiovascular ICU patients treated with CVVHD using the NxStage system vs CVVHDF with the Prismaflex system.

Necrotizing fasciitis is a serious infection that requires prompt surgical excision and broad spectrum antibiotics. Fournier's gangrene (FG) is a type of necrotizing fasciitis that specifically affects the perineal, scrotal, and genital region. FG is a known adverse outcome of the class of medications known as sodium-glucose cotransporter 2 (SGLT2) inhibitors. This class of drugs is most commonly use to treat diabetes, but recently it's use has expanded to include those with heart failure, regardless of whether they have diabetes. With the increased use of SGLT2 inhibitors, the incidence of FG may increase as well. We present 2 case reports of patients who experienced FG while on SGLT2 inhibitor therapy.