Journal of pharmacy practice最新文献

Background: Critically ill adults are more commonly being admitted to intensive care units (ICU) with a recent history of direct oral anticoagulant (DOAC) use. No consensus guidance exists on optimal anticoagulation strategies in critically ill adults with non-valvular atrial fibrillation (NVAF) on DOAC's prior to ICU admission, and there is considerable variability in clinical practice. Objective: To evaluate rates of major bleeding and thrombosis between 2 anticoagulation strategies for NVAF upon ICU admission: package insert (continuation of oral or parenteral anticoagulation per manufacturer recommendations) vs non-package insert (prophylactic dosing or delayed therapeutic anticoagulation). Study design: This was a retrospective cohort study conducted from January 2019 to August 2023. Patients with NVAF and objective evidence of DOAC exposure within 48 hours of ICU admission were included. Those admitted to the ICU for a bleeding event or who received anticoagulation for indications other than NVAF were excluded. Results: A total of 353 patients met inclusion criteria (122 vs 231 in the package insert and non-package insert groups, respectively). There was no significant difference in the composite incidence of major bleeding and stroke or systemic embolism between groups (4.1% in package insert vs 6.1% in non-package insert; P = 0.437). Conclusion: This study demonstrated no difference in the incidence of major bleeding, in-hospital stroke, or systemic embolism with a package insert vs a non-package insert approach to anticoagulation in critically ill patients receiving DOAC therapy for atrial fibrillation. However, more studies are needed to develop evidence-based guidance on anticoagulation management in this population.

Background: Telehealth in the ICU (Tele-ICU) may improve patient outcomes and optimize utilization of high acuity intensive care unit (ICU) beds. However, the relationship between tele-ICU and medication regimen complexity-ICU (MRC-ICU) score is unexplored. Objective: To assess the effect of tele-ICU on MRC-ICU score and describe pharmacists' work. Methods: Adult ICU encounters lasting at least 24 h were retrospectively compared pre- and post- implementation of tele-ICU services in a rural, five-hospital system. The primary outcome was MRC-ICU score 24 h after ICU admission. Prospectively, pharmacist interventions during ICU encounters were captured. Encounters were categorized on exposure to clinical pharmacist review. Results: The difference in mean MRC-ICU score between pre- and post-intervention encounters was -0.2032 (95% CI,-0.8253, 0.4188, P = 0.5217). Post-intervention encounters had a higher rate of thromboembolism prophylaxis (64.5% vs 54.9%, P = 0.001), higher adherence to stress-ulcer prophylaxis (74.1% vs 60.9%, P < 0.001), and a lower presence of glycemic control agent(s) (39.8% vs 46.2%, P = 0.017) 24 h after ICU admission. Tele-ICU services did not significantly change ICU LOS (3.261 vs 3.166 days, P = 0.536), nor ICU mortality (11.1% vs 12.7%, P = 0.377). In the prospective period (n = 196 encounters), 189 interventions were recorded on 80 encounters. There was no difference in median MRC-ICU score at 24 h in encounters with clinical pharmacist review and intervention vs without scheduled clinical pharmacist review (9 vs 8, P = 0.0596). Conclusion: Implementation of Tele-ICU did not change the MRC-ICU score at 24 h, although some ICU bundled care metrics improved. Many encounters lack opportunity for meaningful pharmacy interventions.

Glucagon-like peptide-1 receptor agonists (GLP-1RAs) have experienced rapid growth in recent years as treatments for type 2 diabetes mellitus and obesity. These medications offer promising benefits, including weight loss and improved glycemic control; however, their implications for reproductive health warrant attention. While tirzepatide has been shown to impact absorption of oral contraceptives due to delayed gastric emptying, other GLP-1RAs do not appear to have clinically significant interactions with oral contraception. Fertility outcomes may improve with GLP-1RAs and dual GLP-1/GIP agonists due to weight loss and related metabolic benefits. Despite their widespread use, data on GLP-1RAs in pregnancy and lactation remain limited, leaving significant gaps in guidance for clinicians. This review synthesizes current literature on GLP-1RAs to highlight reproductive health considerations, including their potential impacts on contraception, fertility, pregnancy, and lactation. Greater awareness and understanding of these factors can support informed decision-making and optimize care for individuals using GLP-1RAs.

PurposeThis study assessed the impact of an integrated health system specialty pharmacy (HSSP) on viral load (VL) suppression in HIV patients, compared to patients utilizing non-health system specialty pharmacies (non-HSSPs).MethodsThis was a single-center, retrospective observational cohort study of patients ≥18 years with a HIV diagnosis and an encounter in the outpatient HIV clinic at an academic medical center associated with a HSSP, at least one order for an antiretroviral (ARV) medication, and at least one HIV-1 RNA VL result between January 2018 and May 2022. Outcomes included average rate of VL suppression and socio-demographic factors associated with VL suppression. Comparison of VL suppression between groups was tested using a generalized estimating equation logistic regression.ResultsFrom January 2018 to May 2022, 889 patients met the inclusion criteria; 326 provided VL results while filling at the HSSP and 681 had results while filling through a non-HSSP (118 patients provided results in both groups). Of the 5295 VL results, 90.6% reflected VL suppression, with the average rate of 91.0% in the HSSP group vs 86.0% in the non-HSSP group (adjusted OR = 1.89 95% CI: [1.40, 2.56]). Sex, ethnicity, and race were not associated with VL suppression. However, VL suppression decreased significantly with Charleson Comorbidity Index 1-3; increased with age; and increased over time from VL index date.ConclusionsHIV patients filling ARV therapy through a HSSP had a higher rate of VL suppression than those filling through non-HSSPs, highlighting the potential clinical benefit of this specialty pharmacy model.

PurposeTo describe the utilization of an on-call critical care pharmacist to bridge gaps in clinical coverage for subspecialized critically ill populations.MethodsIn October 2022, a 24/7 on-call team of medical and cardiac ICU pharmacists was established to field questions regarding patients with mechanical circulatory support and pulmonary hypertension. On-call pharmacists were available via centralized telephone number Monday through Friday from 4:00 p.m. to 8:00 a.m., and at all hours on weekends. Information characterizing calls received was collected in an electronic database. A review of all database entries through March 2025 was conducted and descriptive statistics were used to quantify calls received, time spent, multidisciplinary team member engagement, and types of interventions.ResultsOn-call pharmacists received 207 calls and documented 218 interventions. Calls were most often received between the hours of 4:00 p.m. and 8:00 a.m., and the median time spent per call was 10 minutes (IQR 5-20 minutes). On-call critical care pharmacists received the most calls for ECMO patients (38.2%), followed by pulmonary hypertension (26.1%) and Impella® patients (20.8%). The majority of inquiries were from pharmacists (35.7%), followed by advanced practice providers (33.3%) and physicians (21.3%). Anticoagulation and hemostasis was the most commonly cited intervention category (56.4%).ConclusionIn the absence of an onsite critical care pharmacist, a 24/7 on-call critical care pharmacist was utilized by members of the multidisciplinary team to bridge gaps in clinical coverage. Further research is needed to determine the pharmacoeconomic and clinical impacts of on-call critical care pharmacists when onsite resources are unavailable.

Background: Labetalol is an adrenergic antagonist used to manage blood pressure. Current package labeling and drug databases describe intravenous (IV) labetalol's hemodynamic effects to have an alpha-to-beta potency relationship of 1:7, denoting a predominantly negative cardiotropic effect, which differs from our clinical experience. Objective: The purpose of this study was to describe the hemodynamic effects of IV labetalol in clinical practice and compare those results to official references. Methods: This was a retrospective, observational cohort study of patients undergoing evaluation and management for acute ischemic stroke in the emergency department. We included patients who received IV labetalol and excluded those experiencing intracerebral hemorrhage. The primary outcome was labetalol's alpha-to-beta relative clinical potency (RCP), calculated as the median ΔSBP / ΔHR, using nadir values within one hour of labetalol's administration. Results: Forty-two patients met criteria for analysis, with median age of 66 years and majority female sex (71%). Following a median dose of 10 mg, the median ΔSBP was -35 mmHg and ΔHR -9 beats per minute. The median alpha-to-beta RCP was approximately 7:2. Out of 42 patients, 10 experienced excessive reductions in SBP. This cohort exhibited neither new-onset bradycardia nor reflex tachycardia. Conclusions and Relevance: We clinically observed IV labetalol's alpha-to-beta potency ratio to be 7:2, significantly differing from the 1:7 ratio stated in official references. While this study has limitations, our findings highlight an inconsistency between real-world experience and nongeneralizable experimental results. We recommend revision of the official references that intend to guide clinician use of IV labetalol.

Background: For pediatric patients with suspected neutropenic fever in the emergency department, the gold standard antibiotic administration time is 60 min upon presentation. Unfortunately, this is difficult to achieve given operational delays and the lack of multidisciplinary collaboration. Objective: To implement quality improvement strategies to improve the time to antibiotic administration for pediatric patients with suspected neutropenic fever. Methods: Eligible participants included children with suspected febrile neutropenia. A chart review was conducted to determine if intravenous antibiotics were administered within 60 min from triage. Various process-driven and educational interventions were then implemented. The primary outcome was mean time to antibiotic administration from triage. Results: From January 2023 to September 2023, 72 patients were evaluated for the pre-interventions group. From October 2023 to April 2024, 93 patients were assessed for the post-interventions group. The mean time to antibiotic decreased from 92 to 39 min (95% confidence interval [CI], 31.42 to 64.11; P < .001), and the percentage of patients receiving antibiotics within 60 min increased from 35 to 88% (95% CI 0.57 to 0.72; P < .001). Prior to interventions, the major source of delay was the time between nurse triaging and physician ordering of the antibiotic. After interventions, the mean time from triaging to ordering decreased from 34 to 16 min (95% CI, 4.34-31.88; P = .0103). Conclusion: In pediatric patients with suspected neutropenic fever in the emergency department, a multidisciplinary approach and identification of delays in antibiotic delivery can be instrumental in reducing the time to antibiotics administration.

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.

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: 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.