Journal of pharmacy practice最新文献

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.

BackgroundDue to contraceptive access scarcity and other variables, the U.S. exhibits high rates of unintended pregnancy, and Healthy People 2030 has a goal to address this through increased use of birth control. In 2023, Indiana passed legislation allowing pharmacists to prescribe self-administered contraception. Uptake of pharmacist contraceptive prescribing has been limited, and many states are not utilizing this opportunity to advance reproductive equity. We aimed to address significant gaps in literature assessing pharmacists' comfortability and knowledge regarding the implementation and utilization of this protocol.ObjectivesThe purpose of this study was to evaluate pharmacists' comfort and knowledge level before and after a formal education program on conducting contraceptive care via a pharmacist-driven protocol.MethodsThis was a retrospective, cohort study conducted at a safety-net, academic medical center in Indianapolis, Indiana. A formal education program with associated pharmacist surveys took place over two training sessions in November and December 2023.ResultsA total of 30 paired pre- and post-pharmacist surveys were included in analysis (63% response rate). The median [IQR] composite score (knowledge and comfort level) increased pre- vs post-survey from 38 [34,57] to 86 [81,91] (P < .001). Overall correct median [IQR] knowledge scores increased from 40% [40,50] to 70% [60,80] (P < .001). Overall median [IQR] comfort level scores increased from 36% [27,68] to 95% [86 100] (P < .001).ConclusionFollowing completion of a formal education program, pharmacists demonstrated an increase in knowledge and comfort level with prescribing contraception. Intentional training opportunities should be provided to pharmacists prior to implementation. Other health-systems could benefit from offering a similar program.

Background: Over-the-counter topical nasal decongestants are effective and well-tolerated treatments for the temporary relief of nasal congestion, a symptom that can impair quality of life. Their duration of use is limited owing to potential for rhinitis medicamentosa (RM) or rebound congestion (RC), despite uncertainties around the clinical occurrence or onset of these phenomena. Objective: To investigate the clinical occurrence and onset of RM, RC or tolerance with topical nasal decongestants to inform evidence-based recommendation practices for pharmacists and ensure patients do not forego potentially beneficial treatments. Methods: A literature search was conducted with ProQuest to identify and synthesize evidence on RM, RC or tolerance with nasal decongestant sprays or drops. A respiratory specialist and community pharmacist provided clinical perspectives. Results: Eighteen articles were assessed, reporting 13 studies with oxymetazoline, five studies with xylometazoline. There was no evidence of RM or RC after 7 days with oxymetazoline (up to 400 μg total daily dose) or up to 10-days with xylometazoline (840 μg total daily dose). Well-designed studies suggested no occurrence of RM, RC or tolerance with up to 4 weeks of oxymetazoline. No studies evaluating naphazoline, phenylephrine or ephedrine were identified. Conclusion: Oxymetazoline and xylometazoline are highly effective at rapidly improving nasal congestion and have well-established safety profiles. Well-designed studies yielded no evidence of RM, RC or tolerance when used short-term at commonly recommended dosing and frequency. Since some patients may exceed the duration of use in the label, pharmacists can play a vital role in counseling patients on proper intranasal decongestant use and treatment duration.