Journal of pharmacy practice最新文献

Background: Due to their mechanism of action, sodium-glucose cotransporter-2 inhibitors (SGLT2is) carry a presumed increased risk of urinary tract infection (UTI) which is reflected in current prescribing data. As SGLT2i prescribing trends increase, some retrospective studies confirm an increased risk of UTI while conflicting studies find no increased risk of UTI associated with this therapy. Objectives: This study aims to compare the odds of developing a UTI in male Veterans with type 2 diabetes mellitus (T2DM) on metformin taking a SGLT2i vs a sulfonylurea (SU) within the Veterans Health Administration (VHA). Methods: This retrospective cohort study identified male Veterans with T2DM on metformin with a new fill of SGLT2i or SU between January 1, 2020 to December 31, 2022. Patients were then assessed for UTI diagnosis. An adjusted odds ratio (AOR) was calculated. Results: The SGLT2i cohort had 5.2% of patients diagnosed with outpatient UTI and 1.6% of patients diagnosed with inpatient UTI. The SU cohort had 5.3% of patients diagnosed with outpatient UTI and 1.3% of patients diagnosed with inpatient UTI. A logistic regression analysis resulted in a decreased odds of diagnosis of outpatient UTI in the SGLT2i cohort vs the SU cohort ([AOR] = 0.91, 95% CI [0.86 - 0.96], P-value = < 0.001), and no difference in the diagnosis of inpatient UTI ([AOR] = 1.06, 95% CI [0.96 - 1.18], P-value = 0.234). Conclusion: This retrospective study of national VHA data adds to growing literature which finds no excessive risk of UTI associated with SGLT2i therapies.

Background: A Medicare Annual Wellness Visit (MAWV) serves Medicare patients by identifying and addressing gaps in preventive services and health screenings, often aligning with outpatient practice quality metrics. Objective: Evaluate an existing pharmacist-led MAWV telehealth service, determine the baseline quality metric satisfaction rate of telehealth MAWVs, and assess for improvement after implementing a post-MAWV follow-up protocol at a suburban, lower-income primary care clinic. Methods: This IRB-exempt, single-center retrospective chart review utilized the electronic health record at Christ Health Center, Birmingham, AL. From August 2020 through May 2022, 288 charts were assessed between 2 retrospective chart reviews that included patients 18 years or older with Medicare insurance and the ability to conduct a telehealth MAWV. The first chart review assessed metric and recommendation satisfaction within 12 months of the visit. The second chart review was performed after follow-up protocol implementation to assess for additional improvement within 3 months of the visit. Results: The percentage of MAWV recommendations completed groups after implementing a follow-up protocol. For the first chart review, 57.1% of the assessed Health Resources and Services Administration (HRSA), Uniform Data System (UDS) quality metrics, and Centers for Medicare and Medicaid Services (CMS)-required MAWV components were satisfied from the first chart review compared to 53.3% of satisfied quality metrics post-protocol implementation in spite of a substantially shorter follow-up timeframe. Conclusion: Telehealth MAWVs improve preventive care and quality metric satisfaction for Medicare patients. Post-visit follow-up protocols enhance satisfaction rates. Pharmacist-led MAWVs foster interprofessional collaboration and comprehensive patient care.

Purpose: A case of D-penicillamine-related myelotoxicity in a patient with Wilson's disease is reported. Summary: There is a paucity of literature regarding D-penicillamine (DPA) induced myelotoxicity in the setting of Wilson's disease (WD). A 22-year-old male presented with a 1-week history of bleeding gums and dizziness. Four months prior, he had been diagnosed with Wilson's disease and started on a regimen of DPA. His blood counts demonstrated profound pancytopenia. Due to concern for suspected drug-induced myelotoxicity, DPA was discontinued. Parvovirus B19, Epstein-Barr virus, cytomegalovirus, and varicella zoster virus polymerase chain reaction studies were negative and there was no evidence of hematological malignancy. Bone marrow biopsy demonstrated hypocellularity and trilineage hypoplasia with corresponding aspirate flow cytometry confirming the absence of acute leukemia. The patient was started on subcutaneous granulocyte-colony stimulating factor, provided transfusion support with packed red blood cells and platelets. Despite these measures, his blood count failed to recover, and he was discharged on eltrombopag 150 mg daily with plans for outpatient transfusion support. DPA was permanently discontinued, and he was prescribed trientine 750 mg daily. Unfortunately, his myelotoxicity remained consistent, requiring regular transfusions. He is currently undergoing evaluation for bone marrow transplant. Conclusion: DPA-induced myelotoxicity is a rare clinical entity. Our case demonstrates a unique clinical presentation of this phenomenon. Guidelines to mitigate the risk of and treat this toxicity remain to be determined.

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.

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.

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.

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.

To describe a case of Fournier's gangrene associated with ertugliflozin. A 51-year-old male was admitted due to scrotal pain, urinary urgency, and subjective infectious symptoms. He was diagnosed with Fournier's gangrene, likely related to patient's home medication of ertugliflozin. Management and hospital course included antimicrobial and antifungal courses and was complicated by numerous surgical debridements by the urology team. After over 2 weeks, patient was discharged to rehabilitation facility. This report reiterates the importance of awareness of Fournier's gangrene as a potential adverse event of sodium-glucose cotransporter-2 inhibitors, including ertugliflozin.

Sirolimus is an immunosuppressive agent for solid organ transplant recipients and is commercially available as an oral tablet and liquid solution. Current package labeling does not support crushing tablets for administration via feeding tubes. A 72 year old white male presented to the trauma intensive care unit after a motor vehicle crash with a reported history of an orthotopic cardiac transplantation on maintenance sirolimus and prednisone, both of which were resumed on hospital day 1. During admission, the patient required intubation with placement of a nasogastric tube (NG) due to worsening respiratory status. Sirolimus was subsequently given by crushing the tablet and administering via the NG tube. Prior to sirolimus resumption on hospital day 1, a baseline sirolimus level resulted as 2.4 ng/mL and repeat trough levels of 1.7 ng/mL and 2.1 ng/mL were obtained on hospital days 17 and 24, respectively. The patient was discharged to a long term care facility after placement of a tracheostomy and percutaneous endoscopic gastrostomy (PEG) tube with orders to continue maintenance sirolimus and prednisone administered crushed via PEG tube. This report describes a novel administration method of sirolimus in a critically ill adult with detectable sirolimus levels throughout admission. This administration technique appears to be safe and warrants further investigation as a potentially efficacious alternative to standard oral administration.